HomeMy WebLinkAbout2-01-16Paid by General Receipt No. 76 ............. Dated ... ppc. fiA .1976..... , ... .
List Price $.'f *2QQ,,Q,Q *,* Maximum No. Burial spaces .......2...
Discount $ .................. Total area in square feet ................
Net Paid $.* *200.00 ** .. Monument permitted .......... f2atC.....
R &R attched (Data above this line for City Record only)
DEED #306
MC LAIN, gw Marioj
327 Pineapple St, Or Hgts
Lots 15 &16,
B lock 1 Unit #2
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STATE OF FLORIDA
�ARTMENT OF HEALTH & REHABILITA* SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERNIIT
A. _ (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Uecedsed Marion McKay McLain OF Jan. 30, 1985
DEATH
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. Indian River Memorial Hospital
3. Name of Medical "Physician Address
Certifier Gary Silverman, M.D. ❑ Medical Examiner 2300 5th Avenue Vero Beach Fla. 32960
4. Funeral Home/ Name Address
f3f>cnntktxPottinger & 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 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
cause of death.
will complete and sign the medical certification of
was contacted on . He /she verified that
, Medical Examiner, will complete and sign the
ca t tion.
ui rpe 2368 January 31, 1985
6. Funeral Director/ Signature Fla. Lic. No. /Reg. No. Date Signed
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8. BURIAL— TRANSIT PERMIT 759 -593
Permit No.
C
D
Permission is hereby granted to dispose of this body.
❑ A five day extension of timu lut 1111tiIiI Ilia dualh certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed within tins Mite (Unit, a "Funeral Director /Direct Disposer Report" will he filed
with the Local Registrar of the Cuunly In which death occurred.
Registrar or
Sub - Registrar Signatu
w
Date
Issued
In
AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature , Medical Examiner Date
or
Medical Examiner, , gave authurization by telephone to
Funeral Duuclui /l)Uact 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 required for all cremations.
Method of Disposition:
ffrBURIAL []STORAGE
E] CREMATION ❑ OTHER (Specify)
Signature of Sexton 1
or Person -in- Charge ►
EI i i2ibe th Re
CEMETERY UN GhkMATORY
Nlaca ut Disposition .._Sebasti.an_Cemetery
Data of D�sl�usitiu ; ,_
Feb, 1, 1985
Clerk
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
(lepldces previous editions which may be used.)
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