HomeMy WebLinkAbout1-37-03DEED �540 Receipt �360
Paid by CEMETERY Receipt No. .36A. . . . .. . . . . . . Dated . . . .�Q.-�� .-�� . . . . . . . . .
....... No. 05�0
I,.istPricea„300: 00....._��
Maximum No. Pur ' -
3alSpaas .................
Net Paid s 300. 00 AZma Haag and/or Larry Haaq &
.• ... .. . .. .. . . • . .• Momunent permitted . . . .. . .. f1 a t or Jud
••••••••....... / � Cavender
R& R Issued 13225 , U. S, 1{1, Lot#l54
Sebastian, FZa, 32958
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STATE UF FLORIDA � � � ��` `'°`
�PARTMENT OF HEALTH & REHABILIT� SERVICES
VITAI STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERI411T
A. 1Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased O F
PAUL BERNARD HAAG DEATH 20/19/83
2. Place of Deaih : City, Town or Location
County
Name of (If neither, give street address)
Hosp. or
Indian River Sebastian inst. Sebastian River MedicaZ Center
3. Name of AAedical 1� Physician Address
Certifier FCxrhGtt K%iA7�QtijGC� M. D. " ❑ Medical Examiner US #1 �'28C11GY+ BZC�j'. S��QStZCi�, FZ. �
4. Funeral Home/ Name Address
Direct Dispaser StYMqlkF%2''CLZ HO»t2., 734 Nor.th CentraZ Avenue., Sebastian, FZorida
5. Check
Appro-
priate
Box
6. Funeral Director/
Direct Disposer
B.
C
�
a[] The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b J�] Pat (82c �y) was contacted on 10 20 , He/she verified that
ttti�, c�aat� w� fu►rn �ewfal arws�,*�t thsre wiw aq��a�a+eMrnt nar other extemN 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 complate and sign the
medical certification.
FI�. Lic. No./Reg. No.
BURIAL—TRANSIT PERMIT
Date Signed
Permit No.12al�'83�*&�66
Permission is hereby granted to dispose of this 4ody.
� A five day extension of time for filing fhe death certificate (exclusive of weekends) has been requested and
granted. 1f it cannot be filed ithin this time limit, a"Funeral Director/Direct Oisposer Fieport" will be fited
with the Local. Registrar of the�ounty in which death occurred.
Registrar or
Sub-Registrar Si
� �A..�.,..e. .
�
Date October 20, 1983
I ssued
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
01' , ,_..,-.,,,,,,,�.� � ��' ,. ��gs',;,�:ts;:•w-
.. „�,� .
Medical Examiner, , gave authorization by tetephone to '�� i.i�i.�,...,..__
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
Q CREMATION � OTHER (�
CEMETERY OR CREMATORY
Place of Disposition �'P�'►'''�
Date of Disposition �� � -� 1- �,�_
, �� I
Signature of 9extvn--►- ��
w Person-in-Cha�ge J ,
Deborah C. Kraqes, CITY CLERK• City f Se stiar
This permit must be endorsed by the Sexton or peraon-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton)
and returned within 10 days to the Iocal County Health Department in the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.!
,.''
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