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KENNETH �./MARJORIE D. DEED # 484
` CEMETERY . SCHAKE
;
�°, , ' Paid 6y .��idDLReceipt No. . . . 2 9 7. . . . . . : . . . Dated . . . 2 — 2 — 8 2 . . . . . . . . . . . . . . . JQIj�'�LX��K�+'%'�fl�'F�'1�+'�'1C9���
�� 506 N. SeagulZ EireZe
"'7. ,� Iast Price $: . 4 �:Q... Q p .. .. . Maximum No. Burial spaces .2. . . . . .�:3,Z'�,�Of�J t $$ .
y, .�'e��stian,, .F132958
;: Discou,fitt $.*...�k..�:..*:..*.. . Total area in square feet�:..*.. *.,.*...*. UNTT 1 ADD. ,BLK 39 LOT 7&8
, ' Net. Paid $ . . 4.S.Q .: 0.0. . . . . . Monument permitted .f3 a t • . • • • • • • • • • . ,L o t 8 ° Fr a n k D o c t e �a r
� Lot 7 Helen Docteur(HOLD)
12 & R ISSUED WITH DEED (Data above this line for City R.eeord only) ,
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IfE1Vj4'�'� C��'� ANi�I�?� 1�'AI,�JOR�'E�' D�'�°�HAiCE` � 4"
506 NORTH SEAGUL� CIRCLE
BAREFOOT BAY, SEBATIAN, FLA. 32958
BLOCK 39., UNIT #1 ADDNT., LOTS 7& 8
„iDEED # 4 8 4
RECEIPiT # 297
FRANK DOCTEUR, INTERRED IN LOT 8, 2-2-8
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- State of Florida, Departme Health and Rehabilitative Services, Vital S�,�tics
APPLICATIOIQ'FOR BURIAL — TRANSIT PERMIT - �' ���
A. (Type or Print) � ��
1. Name of First Middle �ast DATE Month Day Year
Deceased �el �t1 DoCteur DEATH 03/24l96
2. Place of Death
County
:n�ian River
3. Name of Medical
Certifier
Muh2m�ad Sic'diqui
, Town or Location
�OS2' c"tY1G�
M.D.
4. Name of Funeral Home/
Direct Disposer
Str•ark �uneral i-Icmes,
5.
Check
Appro-
priate
Box
6• Place of Sena:
Final Disposition:
7� Funeral Director/
Direct Disposer
B.
C.
Q
a
Medical Examiner
Name of (If neither, give street address)
Hosp. or
mst. �ebastian River Medical Center
Address
937 Barefoot 31vd.
Barafoot Bay, �lorida
Nhone Numtier
32976 (�07)664-4349
Address Fla. Lic. No./Reg. No. Phone Number (Area c.oae►
1623 PJorth C2ntral Avenue
°.A. Sebastian, F1 32958 1228 i4�7}562-2325
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b[�j Di ana was contacted on ��, �F �4� within 72
hours after death. He/she verified that this death was from natural causes, that there was no accident
nor other external cause of death, and that Muhammad S i dd i qu i, P4 . D. will complete
and sign the medical certification of cause of death.
�❑ was contacted on . He/she verified that
, Medicat Examiner, will complete and sign the
medical certification.
tiStl ��fn2t2t'y state cemetery/ ` Removal
ramatnrv - nama/r.�r�� Inc�i an t'�1 ��/*3i' f—I from state �1 Donation
0
RIAL — TRANSIT PERMIT
F.E. No./Siea. No.
�rt / 8 b
Date
/96
Permit No. 1 �28-96-0159
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 as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a"Funeral Director/Direct
Disposer ReporY' will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filin death certificate request d.
�r Date � /Z � /9 � Duee Certificate
Subregistrar Signature Issued:
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. A waiting period of 48 hours after
death is required for all cremations.
CEMETERY OR CREMATORY
Methods of Disposition: Place of Disposition S eba S t i a n C eme t e ry
� BURIAL ❑ STORAGE Date of Disposition March 27, 1996
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person-in-Charge ) '
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 HRS County Public Health Unit in the County where disposition occurred.
HRS Form 326. Feb 89 �Replaces Oct 87 edition which may be used)
IStock Numbar: 5740-000-0326-21