HomeMy WebLinkAbout2-03-16SHEET NO.
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TERMS
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Alonzo & Hilda
Lakey
Paid by General Receipt No. . 1 Q1.... , . ,
Dated, . ,Nov., , 30,. ,1977 , , , , , • •
27 NW 12th Ct .
Okeechobee
(formerly 332
Pineapple St.)
List Price $.. *200.. Q0. *...
Maximum No. Burial spaces ..... ?.
""
Discount .........
$.........
Total area in square feet ................
Deed # 322
�..
Net Paid *200 DO *„
$............
Monument Flat
permitted .....................
B1k 3, Lots 15
—
& 16, Unit 2
(Rules & Regs. attached)
(Data above this line for City Record only)
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STATE OF FLORIDA
DEPARTMENT OF HEALTH & REHABILI *E SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A (Type or Print)
16 /3 3 z/ a
1. Name of
First
Middle Last DATE Month Day Year
Deceased
OF
Hilda Ruth Lakey DEATH March 28, 1983
2. Place of Death
City, Town or Location Name of (If neither, give street address)
County
Hosp. or
Okeechobee
Okeechobee Inst. H.H. Raulerson, Jr. Memorial Hosp.
3. Name of Medical
ff Physician Address
Certifier Manuel
Garcia,
M.D. ❑ Medical Examiner 308 N.W. 5th Avenue Okeechobee Fla. 33472
4. Funeral Home/
Name Address
WgppgqppWPottinger
& Son Funeral Home 1200 S. Indian River Dr. Sebastian Florida 32958
5. Check
a
The medical certification has been completed and signed. A completed certificate of death accompanies
Appro-
this application.
priate
Box
b ❑
was contacted on . He /she verified that
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.
6. Funeral Director/
BiFik€ )qyr-0j*xx
B.
lei
c ,Aj was contacted on . He /she verified that
' Medical Examiner, will complete and sign the
��Z?al ification.
& " = � - - Z 2368 March 29, 1983
Signatu Fla. Lic. No. /Reg. No. Date Signed
BURIAL — TRANSIT PERMIT
Permit No. 759 -476
Permission is hereby granted to dispose of this body. -
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed within this time limit, a "Funeral Director /Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or �^ ,� Date i-
Sub-Registrar Signature ,�i/ +�`�"i% Issuedli /'
Signature
or
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. Awaiting period of 48 hours after death
is required for all cremations.
D. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cpmrlt Pry
xko BURIAL ❑ STORAGE Date of Disposition March 31, 1983
❑ CREMATION ❑ OTHER (Specify (1/
Signature of Sexton ► // 11 �...- ��-- --
or Person -in- Charge .
Deborah C. Kraaes. Cit
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.)