HomeMy WebLinkAbout2-03-04SHEET NO.
RATING
IT
Paid by Gewral Receipt No. ..... IP.;7 ...... Dated ........ ?--'1-2-71--7,f
List Price Maximum No. Burial spaces ..... ? ......
Discount $ ....... . ........ Total area in square fact ................
A;572�1. Co V
Net Paid Monument permitted ........... Flat .....
Rules & Regs attaChed (Data above this line for City Record only)
Deed # 329
Herman & Shirley Martin
445 Plover Drive
Barefoot Bay ,)z-11C
Unit 2, Blk 3, lots 4 & 5
Herman interred 2123,178
V
it
13
IA
J' -1P -77
! I
Paid by Gewral Receipt No. ..... IP.;7 ...... Dated ........ ?--'1-2-71--7,f
List Price Maximum No. Burial spaces ..... ? ......
Discount $ ....... . ........ Total area in square fact ................
A;572�1. Co V
Net Paid Monument permitted ........... Flat .....
Rules & Regs attaChed (Data above this line for City Record only)
Deed # 329
Herman & Shirley Martin
445 Plover Drive
Barefoot Bay ,)z-11C
Unit 2, Blk 3, lots 4 & 5
Herman interred 2123,178
7
Name-
Unit Z,�,.._..
Block
Lot
Date of Mark -out
Date of Burial Vii- rsi
Name of Funera]Nome �_`_ x" u1,F! � ,4 �°� k`'i /'�6
Authorized by
MAXTXN ' Herman & Shirley
445 Plover Drive
Barefoot Bay
Sebastian, Florida
UNIT 2, BLOCK 3, LOTS 4 & 5
I Al A C D / IAIAM
DEED #329
(Herman interred
Lot 5,2123178)
z
STATE OF FLORIDA N c� ':✓`✓` "�`� ��
DOTMENT OF HEALTH & REHABILITATI *_ RVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Shirley Randall Cross DEATH OF
Dwember 31, 1987
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Brevard Melbourne Ins.. or Hollers Regional Medical Center
Inst. 9
3. Name of Medical ❑ Physician Address
Certifier D.J. Wickham, M.D. (NMedical Examiner 1750 Cedar St. Rockledge, Florida
4. Funeral Home/ Name Addres
Direct Disposer Brownlie & Maxwlall Funeral Ham., 1010 E. Palmeitto Ave., Melbourne, FL
5. Check a The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b was contacted on . He /she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
will complete and sign the medical certification of
cause of death.
)c The medical Examiner IS office was contacted on 1�. He /she verified that
D. J. Wickham , Medical Examiner, will complete and sign the
6. Funeral Director/
Direct Disposer `
B
medical certification.
Signature
596
Fla. Lic. No. /Reg. No.
BURIAL - TRANSIT PERMIT
4, 1988
Date Signed
Permit No. 498037
Permission is hereby granted to dispose of this body.
UKA five day ext nsion of time for filing the death certificate (exclusive of weekends) has been requested and
granted, If i not be filed within this time limit, a "Funeral Director /Direct Disposer Report'" will be filed
with thGAL I egistrav6f ke Coupry in which death occurred.
Registrar or
Sub- Registrar Signature
C.
Signature
or
10
Date
Issued January 4. 1988
AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Medical Examiner Date
Medical Examiner, , gave authorization by telephone to
Funeral Director /Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death
is requirad for all cremations.
Method of Disposition:
n BURIAL ❑ STORAGE
CREMATION []OTHER (Specify)
Signature of Sexton
or Person -in- Charge )
CEMETERY OR CREMATORY
Sebastian Cemetery
Place of Disposition Sebastian, Florida
Date of Disposition
This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer when there is no Sexton)
and returned within 10 days to the local County Health Department in the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)