HomeMy WebLinkAbout1-37-26i
i � � .: _
.� –�.�.— �//�,c,P�
�7 :
r .,
£ -� � . . -
. . . . . . . . . . . . . .-'k � � . .
�y �Q. i�P ' S •
, -� _ 1 �.� � 3 ;
.�
�i `� J
i \� � , ` � � v �'
�� � . �o - ���f.
� x
� � � o � �� y , , .
� � � � �� �
� �
�. ti
� �l\
0
�� �- � � �
�; � ,�Y � ��
,o " .
- � �,�. � �� � � � f �
'� �� _3-�� � � a����� ��� �� �'. � �
� � , ��((� ��,< /` : � �
v � � J
: �� �� � �
�! `�� � � �� ��
�,
� � ,�\� ��,.q : ,� �, _ _ .
_ . Z ,a ,9 � g ��
J1 �� �'
;� �
�. � ,
°�' � �'
,
� � � ,���` ,r`� � ; � _
,� - , � � � �.� ���; � .
p � a�a� � ��
Z.-_ - �, 2 � y'� 3 i j �-
,l:i' '�`QJ ,,�'�. � :
��, o �` , 1 ;
���' . � .�
�4 � �
r\�� p�w �' . ��, : .
, C� �-�
I�
�
!
s
��:
�r
' ��.
Name ^�` �
� � �� i
Unit
BloCk
� -
.�-: ,
Lot
Date of Mark-out
.�,� � � ��` ,�°� �' �fi"'
,n ��,,`� ° �� '� � �1r � '
Date of Burial �� � � � �� ,�� �> " Time �„
Name of Funeral Home ``� � � � '� �=— -
�' k
�tl M
. : �/ .{,, f/•`'� '�� �/,P�� .�,`,
Authorized by
�
i"�
_ ___
_.,..._ -----7�- ...,,
�
J
;
CRAIG"MAE . DEED #508
8b00 U.S. #1,.Lot.72 RECEIPT # 319
RivervieW l�otor Home Villa ;
Sebastian, rlorida 32958
LOT# 25, 26, 27, BLOCI� 37, UNIT #1 `;Addnt,
t� �a� -
/tiTg,e��lj - /H��� <<�g�p�
�a�_
' �� � �.��� ' 7 r� v��
��
�
�
;
�
STATE OF FLORIDA
�EPARTMENT OF NEALTH & REHABILI�VE SERVICES
VITAL STATISTICS
A. (Type or Print)
1. Name of First
Deceased
APPLiCAT10N FOR BURIAL—TRANSIT PERNIIT
Middle
Last
h � ��
� ��
� ��
DA7E Month Oay Year
OF
MAE FLORENCE CRAIG DEATH NOV. 15 1986
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Nosp. or
BREVARD MELBOURNE Inst. W. MELBOURNE HEALTH CARE CENTER
3. Name of Medica� � Physician Address
Certifier JOHN POTOMSKI, M.D. ❑ Medical Examiner 720 EAST �
4. Funeral Home/ Name Address
Direct Disposer STRUNK FUNERAL HOME 734 NORTH CENTRAL AVENUE SEBASTIAN FLORIDA 3295$
5. Check a� 7he medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b� Secretary Pat was contacted on 11 17 86�/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
Doctor Potomski will complete and sign the medical certification of
cause �f death.
6. Funeral Director/
�1ii�K��S�X
B.
C«
�
c� was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
medical certification.
, 11-15-86
Siynature
Fla. Lic. No./Rey. No.
i
� ��7L �
BURIAL—TRANSIT PERMIT
Date Signed
Permit No.1228-86-434
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
yranted. If it cannot be filed within this time limit, a"Funeral Director/Oirect Disposer Report'• will be filed
with the Local Registrar of the County in which death occurred.
Registrar or
Sub-Registrar Signature
�
Date 11-15-86
Issued
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 al� cremations.
Method of Oisposition:
� BURIAL [� STORAGE
� CREMATION � OTHER (Specify)
5iynature of Sexton )
or Person-in-Charge )
G
0
CEMETERY OR CREMATORY
7
Place of Disposition Sehastian Cemetery
Date of Disposition 11/18/86
0
/
This permit must be endorsed by the Se ton o 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
�replaces previous editions which may be used.)