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STATE OF FLORIDA
ARTMENT OF NEALTH & REHABILITAT�ERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERNIIT
.
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A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Lloyd Wilbur Lomman DEATH March S, 1984
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Brevard Micco Insc. 3995 Leslie Drive
3. Name of Medical �cPhysician Address
Certifier Muhammad Faroo�(g, M.D. �Medical Examiner 777 37th St. Vero Beach Fla. 32960
4. Funeral Home/ Name ddres
���� Pottinger & Son Funeral Home 1200 S. Indian River �r. �ebastian 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
will complete and sign the medical certification of
cause of death.
c� was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
medic I certification.
/ _ 2368 March 6, 1984
6. Funeralbirector/
Signature
Fla. Lic. No./Reg. No. Date Signed
B.
C
«
BURIAL—TRANSIT PERMIT
759-537
Permit No.
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 �� ��v-r l��� Date � �u/�, / ���
Sub-Registrar Signat �T Issued—.,,�
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
Signature , Medical Examiner Date
or
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 required for all cremations.
Method of Disposition:
� BURIAL � STORAGE
� CREMATION � OTHER (Specify►
Signature of Sexton ►
or Person-in-Charge )
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
arc ,
Date of Disposition
��
This permit must be endorsed by the Sexton or perspn-in-charge (or b�the Funeral �ector/Direct Disposer when there is no Sexton)
and returned within 10 days to the local County Hea�th Department in e County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.►
BLOCK 39, LOTS 3& 4 Unit 1 Addit.
Deed #548
LOMMAN, LLOYD interred 3/9/84 Lot 4
Aqnes Lomman
3995 LesZie Dr.
Sebastian, FZa.
32958
Paid by CEMETERY Receipt No. . . 4:,._. . � . . . . . Dated . . . .3 / 6. / 8 4 . . . . . . . . . . . . . . ... • NO.
Liat Price S . . .. 4 5 0 , � Q. . . . . Maximum No. Pucial Spacea . . . : 2. : . . . . . . . .
� Agnes Lomman
NetPaids ,,,,450; 00..... Monumentpermitted...,F1at ............. 3995 Lesl ie Dr.
Lots 3& 4, B1ock 39, Unit 1 Addit. Sebastian, F1a.
(Dats above tfifs line !or Gty Rccord ody)
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U548
32958
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THE SEBASTIAN CEMETERY
City of Sebastian
Sebastian, F2orida
RECEIPT IS HSRIs'bY ACKNOWLEDGED OF TNE SUM OF:
FROPl:
�. � � \�... , �,v_ t � � ��, �-�, Dollars (S c.l S r"� . u [� 1
��CI S F�L:�i��l 1>iZ .
St��aS���L �� n. ;3;1ci ti Y
on this � day of (y�c�t �� . 19b yfor the purchase of the following
described Cemetery Lot(s) upon the terms and conditione as stated hereinr
Description of Property:
Cemetery Lot (s) �Y 3-► �i B1ockN � uni t�Y l n��, t' ,
�
Furahe�e Price : �_ <, �-1 ti \�..� •� c � U �- i� �� � �. mllara (S `i S U .UU 1
TermB and'conditions of sale:
This cbntract a�ha11 be b�nding upon both parties, the seller and the purchrutr, �►h�n
approved by the uwnor of the proper•ty above described.
I, or we, agree to purchase the above described property on the terms and c�onditto�u
statad ia the foregoing instrument:
.
The City of Sebastian aqrees to sell the above menttoned property to the ebow na�d
purchaser(s) on the tarse and conditions stated tn the above instrwnant.
Ci t y of 5eba�ttan
Witness