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,, Deed # 147
Paid by General Receipt No. ... �heck:..... DBt�.. �j�29�7D
.. ..... .......... Ken Atha
I.ist Price $..,,,600.00., . �,�im� No. Burial spaces. ..,,8,.. Little Hollywood� 'P.0.8ox 218�
Sebastian, Fla.
Discounfi $........:-......... Total area fn sqnare t6et .
Net Paid $,...600.,00,,,, flat Lots 21�22�25� 31�3��.32�34�35
Monument p�tmitteii ..... .... , ...... B1oCk 36
(Data above tfiis line for Qty Record only) _ Unl t#1
_ --------
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I— �_.__.__
Name�
Unit d
Block �
Lot �
Date of Mark-out
Date of Burial_ �� �,,%�( J �:. • /�,
� �.
Time � � �' �1 *'v
Name of Funeral Home_ ���,� /�� j,( ,(,� �,,� �''"�/
Authorized by „�
�- _ �; � :,�
FLORIDA DEPARTMEVT OF
��
�l�d�i��
q. (TYPE)
1. Name of
Deceased
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSiT PERMIT
First Middle Last Date
of
Margaret Mae Atha Death
2. Place of Death City, Town or Location
County
Name of (If neither, give street address)
Hosp. or
Brevard Litt�� Holl wood inst. 3965 River Oaks Lane
3. Name of Medicai Address Phone Number
Certifier Farhat Khawaja, M. D. 7754 Bay Street
Medic<il Examiner Physician Sebastian, FL 561-589-3000
4. Name of Funerai Home/Ll�st-8ieyeeel Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 1623 N. Central Ave.
Strunk Funeral Home Sebastian, FL 1228 561-589-1000
5. Check a. � The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
Month Day Year
Jan. 22 2002
6. Funeral Director/
B.
L•'
�
b. � Pat was contacted on 1/ Z 3/ 02
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that D r. K ha wa j a wiil compiete and sign the medical
certification of cause of death within 72 hours.
�
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
cause of death within 72 hours.
F.E. No./Reg. No.
� 2�-�.—J� 1862
BURIAL - TRANSIT PERMIT
Date Signed
1/23/02
Permission is hereby granted to cJispose of this body. Permit No. 1 228-02-0038
�A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the rnedical certification of cause-of-death section of the death certiticate within
72 hours.
� No extension of time for filing the death certificate has been requested.
�,�,�;�. Date Date Certificate
Subregistrar Signature n+l �� Issued: 1/ 22 / 02 Due: 1/ 2 7/ 02
Approval Number:
�aUTFiORiZATIOtV for CFi�MATION, D9SS�CTION, or BUF3IAL-AT-SEA
Date
IVledical Examiner, , gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examiner's approva! musi be obtained before disposai by any of the above methods. A waiting period of 48 hours after death is
required for ail cremations.
Method of Disposition:
�G BURIAL � STORAGE
�CRFMATION n OTHER (Specify)
Signature of Sexton
or Person-in-Charge � —��7=�
C:E911��T�FpeY O�R �'.�iEIVIAT�Re
Place of Disposition Sebastian Cemetery
Date of Disposition ,` ��,�9) 7�
—� �
This permit must be endorsed by the Sexton or persori-in-charge (or by the Funeral Dir2ctor/Direct Disposer when there is no Sexton) and returned
within 10 days to the local County Health Department in the county where disposition occurred.
DH 326, 8/97 (Obsoletes all previous editions)
(Stocl< Number: 5740-000-0326-2)
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
GUAROIAN p SAFETy
�.*-TTeZap� � �C'IaH�eAmencan BA
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CITY OF'SEBASTIAN �"� "" � � '�
CITY CLERK'S OFFICE � �'�-' ��.�
RECEIPT , _
Name ., � ❑ Cash
Date ,' '_ p,-Check # �
Amourd Paid
001001 208001 Sales Tax
001501 322900 Garage Sales
001501 341920
001501 341910
001501 362100
00150t 362100
001501 362150
001501 343800
601010 343800
001501 369400
001501 369400
680800 220681
Copies/Bid Specs.
LDC/Code of Ordinances
Community Center Rent
Yacht Club Rent
Non Taxable Rent
Cemetery Lots
Cemetery Lots
Lot/Niche - , Block �'`�' � = , Unit '
Interment Fee
Weekend Service
Yachi Ciub Securily Deposit
�r!..��', �/'i �
680800 220682 Community CenterSecurity Deposit
680800 220683 Riverview Park Security Deposit
f_
,��� ,
�.. .
Total Paid
Initials � ,. ��`J
White - Dept: oi Oripin • Yellow - Finence • Pink - Applicant
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