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D�te of Burial
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Paid by CEMETERY Receipt No. . . . 3 5 6. . . . . . . . . Dated . . . . . . 9 -12 -8 3
ListPriceS.,150; 00,...,..,
Net Paid s I50 . 00
..................
R & R ISSUED
Maximum No. Purial Sp�ces . . . . . . . . 1. . . . . . .
Monument permitted . . . , , , F1 a t. . . . . . _ . . . .
KING, FAYE C./ AND OR SYLVIA DOROTHY
P.O. BOX 247
ROSELAND, FLORIDA
LOT #4, BLOCK 37, UNIT #1:�ADDITION
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� t� �t�-��e �'�rt� %� � n �-�'re� '7 �� 4'�-
Faye C. King
And/Or Sylvia
Doro th y
P.O. Box 147,
No. (�53�
Roseland, FIa.
Lot //4, BZock 37, Unit f11 Addnt.
DEED #� 5 3 5
RECEIPT # 356
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A. (Type or Print)
1. Name of First
Deceased
Itoy
STATE OF FLORIDA u /_� " ��/ — L/�
�PARTMENT OF HEALTH & REHABILITA� SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERNiIT
Middle
'Thomas
Last
lteese
DATE
OF
DEATH
Month Day Year
Nov. S, 1983
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River itoseland Inst. 1286U 82nd Court
3. Name of Medical �Physician Addr s
Certifier Joseph A. Hill � Medical Examiner 2300 Sth Avenue �ero $each Florida
4. Funeral Home/ Name Addres ,
�r,��g�iiPottinger & Son Funeral Home 1200 S. Indian River Urive �ebastian Fla. 32958
5. Check a[�XThe medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b� was contacted on . He/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
will complete and sign the medical certification of
cause of death.
/
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6. Fu ral Director/
@icptm�xxxx
B.
C
0
c� was contacted on . He/she verified that
r\ , � , Medical Examiner, will complete and sign the
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2368 November 5, 1983
Fla. Lic. No./Reg. No. Date Signed
BURIAL—TRANSIT PERMIT 759-512
Permit No.
Permission is hereby granted to dispose of this hody.
� A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed within this time limit, a"Funeral Director/Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or
Sub-Registrar Sign
IDssued �/��' /i � / �•�
AUTHORIZATION for CREMATION, DISSECTION o� BURIAL—AT—SEA
Signature , Medical Examiner Date
or
Medical Examiner, , gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death
is required for all cremations.
Method of Disposition:
�$URIAL � STORAGE
� CREMATION � OTHER (Specify)
Signature of Sexton ►
or Person-in-Charge 1
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetel'y
Date of Disposition November 8, 1983
Deborah C. Kraqes, Ci ty C1erk v � y�J •
This permit must be er�dorsed 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 I
(replaces previous editions which may be used.)
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TNE SEBASTIAN CEMETERY
City of Sebastisn
Sebastisn, Florida 3aqS�
RECEIPT IS XEREBY ACKNOWLEDGED OF THE SUM OF:
D
D�ollars ($ )
o / . � i _ 'a
FROM:
on this �day of ,, 1983 for the purchase of the followinq
described Cemetery Lot( ) u n the terms and cbnditions as stated herein:
Description of Property:
Cemetery Lot (s) # B1ock�1� Uni t# ��_
Purchase Price : ,� �� . /J (� D�ollars ($ , � �)
Terms and'cond.itions of sa1e:
/�G�'.t�/-�� � C�-�=l� � �%� '�` /�O.00J
This c�ontract sha11 be binding upon both parties, the seller and the purchaser, when
approved by the owner of the propertg above described.
I, or we, agree to purchase the above described property on the terms and conditions
stated in the faregoing instrument:
�� � .
The City of Sebastian agrees to se11 the above mentioned property to the above named
purchaser(s) on the terms and conditions stated in the above instrument.
.�J
C y of Sebastian
Witness