HomeMy WebLinkAbout2-05-12Paid by General Receipt No. ............. DatedV1 .2180 ...................
List Price Maximum No. Burial spaces ............
Discount $.....7............ Total area In square feet ................
Net Paid $-*. 10D.DOAt— Monument permitted .....................
R&R attached (Data above this line for City Record only)
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DEED #393
Lincoln, Ray
(Wife Kay interred 4114180
549 SW jay Street P-O.Box 223(,
Sebastian, Fl
BLK 5 LOT 12 UNIT #2
/9-
BLOCK 5 LOT 12 UNIT #2
Mr. Ray Lincoln (wife, Kay, interred 4114180)
549 SW Jay Street
P. O. Box 2236
Sebastian, Fl 32958
DEED 393
STATE OF FLORIDA
9 DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL. STATISTICS i-
APPLICATION FOR BURIAL -TR IT PERMIT
DATE Month Day Year
NAME OF
First Middle Lost OF
DECEASED Ka A Lincoln DEATH April 11, 1280
(Type or print) y
NAME OF (lt not in hospital, give street address)
PLACE OF DEATH 7CITY,7T�DwN, OR LOCATION HOSPITAL OR
COUNTY Indian River Beach INSTITUTION I
Attending Physician PYC (Name of Medical Certifier) (Address)
Medical Examiners ❑ Thomas A. Jack'son, M.D. 2175 20th St. Vero Beach Flotilla 32960
Funeral (Name) (Address)
Home Colonial Yuneral Home S. .Indian River Drive Sebastian Florida 32958
Check A [g A completed certificate of death accompanies this application.
One
B ❑ Dr. was contacted on ,19
He has assured me that this death was from natural causes and that he will complete and sign the medical
certification of cause of death.
C ❑ The attending physician was unavailable or this death comes within the Medical Examiners jurisdiction.
The body was released to me by
19
q
April 11, 1980
(Signature) (Fla. Lic. No.) (Date Signed)
Fune?"al
Director
Permit 759-272
BURIAL TRANSIT PERMIT No.
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For cremation a
waiting period of 48 hours after death must be observed and the Medical Examiner's approval must also be obtained',
❑ A five day extension of time for filing the death certificate has been requested and granted.
r)atp
CEMETERY OR CREMATORY
Method of Disposition Date of Apr11 14, 1980
BURIAL Disposition
-� CREMATION
1 S Place of
STORAGE
]
Disposition Sebastian Cemetery
OTHER(Specify)
Signature of Se**eo
or Person in Charge
This permit must be endorsed by the sexton or person in charge (or by the funeral director when there Is no sexton) and returned
within 10 days to the local county health department.
HRS Form 326 (1/77)
M