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STATE OF FLORIDA
�ARTMENT OF HEALTH & REHABILITAT SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERNiIT
� /� /� �7 �fif�
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
BEULAH RUTH GOLIEN DEATH Sept. 6, 1983
2. Piace of Death City, Town or Location Name of (tf neither, give street address)
County Hosp. or
Indian River Sebastian �nst. 585 Peterson St., Sebastian
3. Name of Medical �(Physician Address
Certifier Muhartmad S i dd i qu i, M. D. ❑ Medical Examiner 935 Ba refoot Bay E31 vd ., Barefoot Bay, F 1.
4. Funeral Home/ Name Address
Direct Disposer Strunk Funeral Plahe. , 734 North Central Avenue. , Vero Beach, Flor ida
5. Check
Appro-
priate
Box
6. Funeral Director/
Direct Disposer
a[� The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b� D r. S i dd i qu i was contacted on �_. He/she verified that
this death yr_as from natural causes, that there was no accident nor other external cause of death, and that
He will complete and sig� the medical certification of
cause of death.
c� was contacted on . He/she verified that
certification.
, Medical Examiner, will complete and sign the
Fla. Lic. No./Reg. No.
1672
BURIAL—TRANSIT PERMIT
Date Signed
September 7, 1983
1228-83-227
Permit No.
Permission is hereby granted to dispose of this body.
� 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
wjth ihe Local Registrar of the County in which death occurred.
Registrar or
Sub-Registrar
C.
Signature _
Of
�
�
Date
Issued
September 7, 1983
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
, Medicaf Examiner Date
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:
XX� BURIAL � STORAGE
� CREMATION � OTHER (Specify)
Signature of Sexton )
or Person-in-Charge ►
CEMETERY OR CREMATORY
Place of DispositionSebastian Cemetery
Date of Disposition 'september 9, 1983
Deborah C. Kraqes, Citi� C1erk � ��
This permit must be endorsed by the Sexton or person-in-charge Ior 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.)
.Dated.. q-7-83
Paid by CEMETERY Receipt No. . . .3 5 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I,ist Price S . I S 0. :� �. . . . . . . . . Maximum No. Eucial Spaces _� .- . . . . . . . . . . . . .
. Z S 0 . 0 0 Monument permitted , f 1 a t . . . . . . . . . . . .
NetPaid S .................. ........
R& R ISSUED (Data above tl�is 11ne tor Cit,i' RecoTd °°�y�
BLOCK 37
LOT 19
E1mer Golien
585 Peterson Street
Sebastian, FIa. 32958
N�� 0533
ELMER GOLIEN
585 Peterson Street
Sebastian, Florida
32958
Receipt #355
LOT #19, BLOCK 37,UNIT#1,ADDNT,
UNIT #1 ADDNT.
BEULAH GOLIEN, INTERRED 9/7/83, in Lot #19, B1ock 37,
Unit #1, Addnt.
l J
�
THE SEBASfiIAN CE!lETERY
City of Sebastian
Sebastian, Florida � �J c,
RECEIPT IS HEREBY ACKNOWLED6ED OF THE SUI►! OF:
FROM:
J
. �-�. � �
on this day of , 138,� for the purchase of the followinq
described Cemetery Lot s) u n the terms and conditions as stated herein:
Description of Property:
Cemetery Lot(s)# � 9 Block# �,�Unit# � C��
Purchase Price: ���, G v D�Ilars ($ ��(j. � j
Terms an d'co�di i ans of sa1 :
��l�t �� � .� �/..SD. Od � G� ��/�7
This contract sha11 be binding upon both parties, the seller and the purchaser, when
approved by the owner of the property above described.
I, or we, agree to purchase the above described property on the terms and conditions
stated in the foregoing instrument:
� �
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The City of Sebastian agrees to se11 the above mentioned property to the ahove named
purchaser(s) on the terms and conditions stated in the above instrument.
Witness
m
%i/_ � ��
'ty of Sebastian '