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STATE OF FLORIDA %�,, n 3� ///�
EPARTMENT OF HEALTH & REHABILIT E SERVICES f�' �� �1
VITAL STATISTICS �
APPLICATION FOR BURIAL—TRANSIT PERMIT
A• (Type or Printl
t. Name of Fi�st Middle Last DATE Month Day Year
Deceased O F
CHARLES L. HANOOCK oEatH April 9,1983
2. Place of Death City, Town or Location Name of (If neiiher, give street address)
County Hosp. or
Indian River Sebastian i�st. Sebastian River 1'1ec?ical Center
3. Name of Medical Physician A dress
Certifierj��p KC1S0� M.D. �Medical Examiner $�th Ave. � SC�astian, Floricla
4. Funeral Home/ Name Address
Direct Disposer $trunk Funtral Home 734 N. Cenral Ave. Sebastian Fl. 32958
5. Check a� The medical certification has been completed and signed. A completed certificate of death accompanies
App�o- this application.
priate b � Kelso
Box 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
HP will complete and sign the medical certification of
cause of death. •
��
6. Funeral Director/
Direct Disposer
medical certification.
Signature
was contacted on . He/she verified that
., Medical Examiner, will complete and sign the
Fla. Lic. No./Reg. No.
Z�A8
Date Signed
il Il. 1983
B• BURIAL—TRANSIT PERMIT
Permit No. 122c�-83-106
Permission is hereby granted to dispose of this hody.
� 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 ihe County in which death occurred.
Registrar or
Sub-Registrar Signatu
C.
Signature
or
C
Date Apr'il 11 � 1983
Issued _ _
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. A waiting period of 48 hours after death
is required for all cremations.
Method of Disposition:
� BURIAL � STORAGE
� CREMATION � OTHER (Specify)
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemeteru
Date of Disposition 4-11-83
Signature of Sexton ► .,
or Person-in-Charge ► i Q !� ��Q
DEBORAH C. KRAGES, CITY CLERi
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 �ocal County Health Department in the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
4-��-83 ... NOi Q S � ,1
.....Dated ...........................
Paid by CEMETERY Receipt No. . 3 4 . . . . . . . .
��as,..$300:OOf150. Each) M�umNo.EuiialSpaces.....-�:......... Deed #527,
Flat Receipt �349
Net Paid S 300 00 Monument permitted . .. .. . .. .. . .. . .. . . . . . . • Agnes Hancock
...... ..:..........
Box 176, Sebastian,Fla.
R& R Issued (D�t� +►bove tbis W�e to* (�U' �� �b'i Lots 5& 6, B1ock 39 , Unit #1 Addnt
_ - _- _ -----. _ _ _ _ J
HANCOCK, AGNES
BOX 176
SEBASTIAN, FL8&IDA 32958
DEED # 527
Receipt #349
LOTS 5& 6, Biock 39, Unit I�1 Addition
�:
Charlie Hancock Interred in Lot N5 4/IZ/83
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R£CEIPT IS HEREBY
FROA1:
�
TXE SEBASTI.�l1P C£!lETERY
City of Sebastiari
Sebastian, Florida
OF TXE SUM OF:
3�9
b � ars (S .)
on this�day of , 19$� for the purehase of the fo3lowing
described Cemetery Lot(s) pon the terncs and cond2tions as stated herein:
Description of Property:
Cemetery Lot (s} #�,S 4c- �p B1 ock#�� Uni t# ��
Purchase Price:���'/�,�,1(���j(�,�j• Dellars(S Q,Q(J)
�7--
Terms and�condlti ns of sa1e:
� , C`��C �/�9.3 ���o.o v , �
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This cor,tract sha11 be binding upon both parties, the seller and the purchaser, when
approved b� the owner of the property above described.
.T', or we, agree to purchase the above described propert� on the terms and conditions
staated �n the foregoing instrument:
The City of Sebastian agrees to se31 the above mentioned property to the above named
purchaser(s) on the terras and conditions stated in the above instrument.
Witness
.�/� � � ' � �
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