HomeMy WebLinkAbout2-03-13Paid byWin'Fi9ceipt No. 112...... .... Dated ........ �7=e-.215,297.8..
2
List Price $.. *.35.0:.00.*.. Maximum No. Burial spaces ............
Discount $ ......... rm ....... Total area in square feet ................
Net Paid 35 0. 0.0.. *. .... Monument permitted .... Flat ...........
(Data above this line for City Record only)
Deed # 333
Matthew & Florence Carroll
Box 184-C, Palm Avenue
Micco, Florida
Matthew interred 6-11-78
Unit 2, Blk 3, lots 13 & 1
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COLORADO DEPARTMENT OF HEALTH
DISPOSITION - REMOVAL PERMIT NO. �iK d 781
NAME OF DATE OF
DECEDENT MATTHEW WILLIAM CARROLL _ SEX M DEATH .1uma 341 1978
DATE PLACE
AGE 85 BIIRTHOFApr11 70 199 DEATH OF
UN STATE
CAUSE
DEATH OF Messenteric artery thrombosis
IN ACCORD WITH THE LAWS OF THIS STATE, PERMISSION IS HEREBY GIVEN TO THE FUNERAL DIRECTOR NAMED
BELOW, DULY LICENSED BY THE STATE OF COLORADO, TO DISPOSE OF THE BODY IDENTIFIED ABOVE.
Evergreen Funeral Home Fountain F fin ion polo s^ ^s X 18
NAME OF FUNERAL DIRECTOR �� �� DR
TYPE OF
DISPOSITION Removal _ PLACE Florvida
CEMETERY OR CREMATORY STATE
REGISTRATION DISTRICT 69 Afi�C�'uvi egVA4,4
DATE June 15. 1979 `-C
SIGNATURE, LOCAL REGIS RAR
ITEMS BELOW TO BE COMPLETED BY CEMETERY OR CREMATORY OFFICIAL:
_BODY WAS-&a--:- �_� {mob 7 _ ON C.� -+ / I �9 %;i IN LOT '1 BLOCK SECTION
PLACE .f .. `I/ _ L
'�-
AD RS SIGNATURE, SEXTON OR PERSON IN CHARGE
3 REV. 2 -69 -250 2 }
Block 3 Late 13 do 14 Unit 2
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Carroll, Matthew and Florence
Box 184 -C, Micco
Matthew interred 6/19/78 - lot 13
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Deed 333