HomeMy WebLinkAbout2-03-06--P e...e.. -W 36-3 ✓
Paid by General Receipt No. —2,34 ...... .... Dated..... May.. J.,. 1979 . ......... Dale Robt. Hall (deceased)
List Price ;1.Q0.00.•. Mr. & Mrs. Harry Spaulding
Maximum No. Burial spaces 2.......... Baird Street
Discount $.... :T ............ Total area in
Net feet ................ Roseland, F1 32957
Net Paid lo 00 $p.
. ............... Monument permitted ...
(Data above this line for City Record only) Blk 3 Lot 6 Uni t 2
RATING
CREDIT LIMIT
17
A-
4- 77
Hall ,'Dale Robert
P. O. BOX
Roseland F1
13
Iii
VI/
oc3n9-0 Mr. & Mrs. Harry Spaulding
Baird Street
Roseland, F1 32957
d'
Deed #353
Block 3 Lot 6 - unit 2
Mr. Dale Robert Hall interred 3118179
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STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRA IT PERMIT
PIMn
NAME OF First Middle Last DATE Month Day Ysar
DECEASED r Rob Hall DEATH March 18 � 1.979
(Type or print) D ale eat
PLACE OF DEATH CITY, TOWN, OR LOI -TION NAME OF (If not in hospital piw street
COUNTY Indian River Roseland HosvlrAL oR Sebastian fiver ISed. C
INSTITUTION DOA
Attending Physician ❑ (Nome of Medical Certifier) (Address)
Medical Examinen73X John Rodgers, M.D. 1000 36th Street Vero Beach Flo ir3a ipaF:
Funeral - (Nome) (Address)
H It Colonial Funeral Home S. Indian River Drive Sebastian Florida 32958
Check A 9 A completed certificate of death accompanies this application.
One
B ❑ Dr. was contacted on , 1 q
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
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(signature) / �Z (Flo. tic. No.) (Date signed
Funeral
Director
BURIAL TRANSIT PERMIT Permit
No. :i.7—
Permission is hereby granted to dispose of this body_ by burial, _transportation out of state, storage or crellnation. 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.
Signature of
Registrar
Method of I position
BURIAL
❑ CREMATION
❑ STORAGE
❑ OTHER (Specify)
Signature of be~
or Person in Charge
x.
Date
Issued
COY OR tN11MATORY
Date of
Disposition d t�.� Of �y7,9
Place of or
Disposition
This permit must be endorsed by the sexton or person in charge for by the funeral director when there is no sexton)
and returned within 10 days to the local county health deportment.
1 `
HRS Form 326 (1/77)
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