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Paid by CEMETERY Receipt No. .., 3 61. ......, Dated .... D e c e m b e t, 9. , Z g 8.3
......... No. 0543
I.ist Price s,,, 15.0 ; 0 0
• . . . . . . . . Maximum No. Pucial Spaas -1 -
"""••••••••••• Dorothy Roux
I50.00 312 S.W. Benedictine Terr.
Net Paid S . . . . .. . . . . . . . . . . . . . Monument perntitted . . . F 1 a t
...........
�� Sebastian, Florida 32958 �
Lot I1, B1ock 37, Unit Z Additional
(Data RDove thh lfne for pfj� Record only)
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ROUX, DOROTHY DEED #543
312 S.W. Benedictine, Sebastian
Lot 11, BZock 37, Unit 1 Additional
Wilfred Roux interred 12/9/83
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STATE OF FLORIDA
ARTMENT OF HEALTH & REHABILITA� SERVICES
V17AL STATISTICS
APPLICATtON FOR BURIAL—TRANSIT PERNtiT
A. (Type or Print)
t. Name of First Middle Last DATE Month Day Year
Deceased Wilfred Luke Roux D ATH Dec. 6, 1983
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Roseland 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/ I�me �`�q�e Sebastian Florida 32958
������ Pottinger & Son uneral Home 1200 S. Indian Rive
5. Check a� The medical certification has been completed and signed. A completed ce�tificate 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. Fune�l Director/
was contacted on . He/she verified that
., Medical Examiner, will complete and sign the
�2368 Dec. 7, 1983
Fla. Lic. No./Reg. No. Date Signed
BURIAL—TRANSIT PERMIT
Permit No. ��" `r�7
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 ,,��VyI i/%���C�C% Date �! l��
Sub-Registrar Signature �/_T (� Issued � �
C. AUTHORIZATION for CREMATION, DISSECTION or 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:
[y�BURIAL � STORAGE
� CREMATION � OTHER (Specify)
Signature of Sexton ►
or Person-in-Charge )
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition December 9, 1983
This permit must be endorsed by the Sexton or person•in-charge (or b�%the Funeral Director/Direct Disposer
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.►
is no Sexton)
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� � TNE SEBASTIAN CEMETERY
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�� t �� City of Sebast.ian
� \ ��, Sebast�an, Florida
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' RECEIPT IS HEREBY AC OWLEDGED OF THE SUM OF:
�� Dollars 1�_�Q. �� )
FFdOM:
on this � day of ., 198� for the purchase of the ollowing
de�cribed C�y �tls1 upon the terms and conditions es statec�herein:
�
Description of Property: I
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Cemetery LoE (s) �Y �� B1ock�y��UnitN� —
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Purchase Price: � J�� [�. � AD1��$�S )
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Terms and conditions of sale:
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This contract sha11 be binding upon both parties, the seller aid t�e purchaser, when
approved by the owner of the property above described. '
I, or we, agree to purchase the above described property on �e te�os ari( conditions
stated in the foregoing instrument:
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The City of Sebastian agrees to se11 the above mentioned �'operty � the abo�e natned
purchaser(s) on the terms and conditions stated in the ab►ve instr�e»t. �
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ty o �abastisn ,
Witness