HomeMy WebLinkAbout1-38-22__ _ _
� °-�'��- �g'
£ _ . -
L--
,
� �_ i : I� � �� � I �/ � � - : i - -
- .:a------_ _ ° . �-
Paid by CEMETERY Receipt No. . 3 7,Q , , , , , , , , , , Dated . 6, / 4 � 8 4. , , . . . .
List Price S . . .4 5 0. : 0 0 . . . . . . . . . . N0.
. . . . . . Maximum No. Eutial Spaoes . . . . . . . ?. .
Net Paid S... 9 5 Q. . O Q. ..... F I a t..... � 1' �� U J
Monument permitted . . . . . . . . . . . . . . . . . . . . . .
Lot 21 & 22, Block 38, Unit t/1-Add. Mrs. Mildred Morqan
(Dah abo�e t�L lfnt for Cit �� od 41 9 P 1 o v e r D r i v e
% Y) Sebastian,FL 32958
STATE OF FLORIDA
�PAR7MEN7 OF HEALTH & REHABILIT,•E SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERNIIT
A. (Type or Print)
1. Name of First Middle
Deceased
Raymond Neale
2. Place of Death City, Town or Location
County
Indian River Roseland
Last
Morgan
! :� � � � 8 �/ l �t
DATE Month
OF
OEATF4Tune 1,
Day Year
19 �34
Name of (If neither, give street address)
Hosp. or
Inst. Humana Hospital Sebastian
3. Name of Medical � Physician Address
Certifier Muhammad Siddiqui, M.D. �Medical Examiner 935 Barefoot Blvd. Sebastian Fla. 32958
4. Funeral Home/ Name Addre
����Pottinger & Son Funeral Honiel2@0 S. Indian River Drive �ebastian Florida 32958
5. Check a c� 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 acciderit nor other external cause of death, and that
will complete and sign the medical certification of
cause of death.
6. Funeral Director/
RX����X
B.
C
�
c
gn
J
is contacted on . He/she verified that
Medical Examiner, will complete and sign the
2368
Fla. Lic. No./Rey. No.
BURIAL—TRANSIT PERMIT
June 1, 1984
Date Signed
Permit No. �� y'�,C��
Permission is hereby granted to dispose of this 4ody.
❑� 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 Reyistrar of the County in which death occurred.
Registrar or
Sub-Registrar Signatu
Date
Issue
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
�1�'
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
Date of Disposition June 4, 1984
This permii 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
(replaces previous editions which may be used.)