HomeMy WebLinkAbout1-37-24i
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STATE OF FLORIOA ^ fj, ^;7 –� ay
�PARTMENT OF HEALTH & REHABILIT�E SERVICES � �'� .�
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased O F
FLORENCE BEATRICE GORE DEATI-bct. 23, 1982
2. Place of Death City, Town or Location Name of (If neither, give street address)
County • Hosp. or
Indian River Vero Beach Inst. �ndian River Memori�+� Hospital
3. Name of Medical � Physician Address
Certifier�ohn H. Terry, M. D. ❑Medicai Examiner 30 Royal Palm Blvd. Vero Beach, F1, 32960
4. Funeral Home/ Name Address
DirectDisposer Strunk Funeral Home 916 17th Street Vero Beach, Florida 32960
5. Check a� The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b� Dr. Terry was contacted on Mon�/ � e/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
Dr. Terry will complete and sign the medical certification of
cause of death. ,
�� was contacted on . He/she verified that
6. Funeral Director/
Direct Disposer
B.
C
D.
medical certification.
re
Medical Examiner, will complete and sign the
Fla. Lic. No./Reg. No. Date Signed
BURIAL—TRANSIT PERMIT
OCt.
Permit No. �30-1235
Permission is hereby granted to dispose of this body.
�] A five day extension of time for tiling the death certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed within this time limit, a"Funeral DirectorlDirect Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or .:`���,C/ Date
Sub-Registrar Signature —__ __ 1 Issued OGtober 25, 19$2
Signature
or
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
, Medical 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 require�' {or all cremations.
CEMETERY OR CREMATORY
Meth: Jisposition:
� BL; ",L � STORAGE
� CREiviATION � OTHER (Specify)
Signature of Sexton ► i'� /� ����
or Person-in-Charge ) �.k�
City Clerk
/
. � �c
Place of Disposition Sebastian Cemetery
Date of Disposition 10-26-82
This permit must be endorsed by the Sexton or person-in•charge (or by the Funeraf 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.
NRS Form 326, APR. 81
�replaces previous editions which may be used.)
Paid by CEMETEgy Receipt No. .. 320 10-27-82
List Price $ . .225 ; 00 . . . . . . • . .. . . . . . . Dated . . . . . . . . . . . . . . . .
x�r P�a a . . . . . . . . .
R & R ISSUED
Maximum No. Eurial Spaces . . . .1. . . . . . . . . . . .
Monument pernutted . . . . . k'.j. a � . . . . . . . . . . . .
(Data sbove ti�ls line tor C1tJ' liecord onlY)
NO. Q�(l�
v
James Gore
12975 93rd Place
Fellsmere, Fla.
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LOT 23,� Block 37, Unit #1 Addn.
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TXE SEBASTIAN CEMETERY
City of Sebastisn
Sebastian, Florida
RECEIPT IS XEREBY ACKNOWLEDGED OF TiIE SUM OF:
�`-�i%�
%� 97� �3 �.C�.-w
..�.�s � . 3/', .3a 9�s�7
�� V
!S o%•?S , � I
on this � day of ��.'t�. , 1982 for the purchase of the following
described Cemetery I.ot(s) upon the terms and canditions as stated herein:
Description of Property:
Cemetery Lot(s)i� p�� Block# ✓ Unit#! ���- •
Purchase Price: ars($ o�o7�e?�
�
Terms and'c�onditions of sa1e:
'��
This contract shalZ 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: �
The City of Sebastian agz�ees to se1I the above mentioned property to the above named
'purchaser(s) on the terms and cbnaTitians stated in the above instrument.
witness
�
ity of Sebas
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