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DEED #454
Paid b C����u P June 16, 1981 MitchelZ, Henrg A. and or
y t4ecei t'No. .45.4. Dated. . .......
. , ... .... MitchelZ,. Carol L.
List Price $. *$200. 00* . �Mnximum No, Burial spaces ..� .. 8005-142nd Street :(Roseland)
***,�.****�.** Sebestian;, ��1oxi°da . 32958
Discount $.. -Q .... Total area in aqnare �feet •
• Net Paid .$•.*.52.00..0�:. . Monument permitted� '.f.Z�t•. Unit #1 Add. � Blk. #39� Lots 256�26
(Data above tlils line for City Record only)
R. &. R. issued with.'Deed ' ',
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Name �%�. .�• � rf"'�.f'i�- =
Unit .. ;',
61ock � �
Lot �` �
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Date of Mark-out � "
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Date of Burial � � Time' ��' � t�G� t� '�
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� . Name�
I Hom "�'�I� JU %� ,� .,
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Autho � by
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DEED#' 454
MITCHELL, Henry A.
MIZiC�LL, 'Caro1 L.
8005 142nd Street (RoseZand) ,
Sebastian, FZorida 32958 -
UNIT # 1 Addition BLOCK # 39 LOTS #?�5 & 26
' ,�r.' - �� �s- � aa-��
FLORIDA DEPARTMENT OF
HEALT
A. (TYPE)
1. Name of -- -
Deceased
. ._ State�lorida, Department of Health, Vital Sta�s
. � ... .. � . . :: �._ .. � r, �
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` APPLICATION FOR BURIAL -_TRANSIT PERMIT � �
. . .. -• � 3 r ' , . ' . . . _. � . . -.. :
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First - _ __ _ ._ _.Middle -.___ ___. Last --.--_----- - - Date Month .- -DaY----- Year
Henry Albert �� Mitchell Death Sept. 19 1999
2. Place of Death City, Town or Location
County
I ndian River Sebastian
Name of (If neither, give street address)
Hosp. or _ ,� _
inst. 8005 142nd Street
3. Name of Medical Address Phone Number
,_ _ .-. _ _ . .,; � .
. � . _ _,
cert�fer iVlichael Vu, � M D.� "`� 981 37th Place � -�
nnedical Examiner Physician Vero Beach, FI 32960 561-770-5800
4. Name of Funeral Home/Bire�Biepeed Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Estabiisnment �� ' = �=� = '7°'� 1623-N. Central Avenue > °
Strunk Funeral Home^ '` 'Sebastian, FI � 1228 '561-589-1000
5. Check a. � The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application. _ _ :
Box <
b. �i He i d't was contacted on 9/ 2 0/ 99
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dt'. VU will complete and sign the medical
cert�cation of cause of death within 72 hours. �
�. � was contacted on He/she verified that
- . . _ _ � ._ A -_- -- - - - ; Medical Examiner, will complete and sign the
6. Funeral Director/
B.
of death within 72 hours. '-_
i F.E. No./�R i. No.
y� ' �J/-� �
BURIAL - TRANSIT PERMIT
Date �Si�gnSed
- o� '
Permission is hereby granted to dispose of this body. Permit No. 1228-99-0433 -
� A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the .physician has
3� .
been cont�cted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours. -
�No extension of time for fiting the death certificate has been requested. -- - -- --- ------
• ' "` - Date .,, , ` _ Date Certifica
Subr� egi� stx a Signature � %��R,�Q _ Issued: � d Due: q
c. � �, AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA =-- `�� ��" �
Approval Number. Date - �
Medical Examiner, , gave authorization by telephone to
Funeral DirectodDirect 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. _
p. , CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cemetery
�BURIAL
�CREMATION
Signat�re of Se�on
or Person-in-Charge
�STORAGE
�OTHER (Specify)
�
'
Date of Disposition September 2j�, 1999
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.
DisVibutian: Whde: Cemetery or Crematory
DH 326, 8197 (Obsoletes all previous editions) Yellaw: Funeral Director or Dired Disposer
(Stock Number 5740-000-0326-2) Pink Local RegisVar