HomeMy WebLinkAbout1-24-26 Name • 0 Id � _'
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unit
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Block 2 V
Lot 2 6
Date of Mark-out 5-13 /7°
Date of Burial tU / 2 /� / Time / 04)/A3
Name of Funeral Home 5.1ka lel 1.4 7.m 6
Authorized by._�. � t 1 Lt.. t ,�� : •
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FLORIDA DEPARTMENT OF 'l
• HEALT State of Florida, Department of Health,Vital Statistics u f
APPLICATION FOR BURIAL-TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
Thomas M. McPherson Death 5-30-01
2. Place of Death City,Town or Location Name of (If neither,give street address)
County Hosp.or
Indian River Vero Beach Inst. Indian River Memorial Hospital
3. Name of Medical Address Phone Number
Certifier Taher Husainy, M.D. 2300 5th Avenue
nMedical Examiner J Physician Vero Beach, FL 32960 (561) 567-7111
4. Name of Funeral Home/Direct Disposal Address Fla. Lic.No./Reg.No. Phone No.(Area Code)
Establishment 916 17th Street
Strunk Funeral Home Vero Beach, Fl 32960 0130 (561) 562-2325
5. Check a. 1=1 The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. IN Jackie was contacted on 5/30/01
He/she verified that this death was from natural causes,that there was no accident nor other external cause of death,
and that Dr. Husainy will complete and sign the medical
certification of cause of death within 72 hours.
c. was contacted on He/she verified that
,Medical Examiner,will complete and sign the
medical certification of cause of death within 72 hours.
6. Funeral Director/ // nar , _ F.E. No./ReNo Dcs® -
c i i
B. BURIAL -TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 0130-01-0276
0 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 medical certification of cause-of-death section of the death certificate within
72 hours.
I=INo extension of time f r filing the death certificate ha been equested.
Registrar or I Date Date Certificate
Subregistrar Signature Issued: 5/301 01 Due:
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number: 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.
D. CEMETERY OR CREMATORY `
Method of Disposition: Place of Disposition 5 k".,BA S I� 4 TA a v"v,I yE e„
RIBURIAL STORAGE Date of Disposition ..1 p
0CREMATION DOTHER(Specify)
Signature of Sexton } y
or Person-in-Charge ll Q
This permit must be endorsed by the Sexton or 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.
Distribution: white: Cemetery or Crematory
DH 326,8/97(Obsoletes all previous editions) Yellow Funeral Director or Direct Disposer
(Stock Number 5740-000-0326-2) Pink: Local Registrar
Flock 2/1 Lots 2E., 27, 2A, 29, 30 unit. 1 c).
31, 32, 33, 3)4, 35
a/k/a Lot 4
McPherson %
L 11111 11111 .
r- McPHEPSON, /
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(Odessa, Thomas TAI.)
UNIT 1 O.B., Block 24, Lots2626 27, 26, 29,
3l, 30
a/k/a Lot 4
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... ." SUBSCRIBED AND SWORN TO THIS 30th DAY OF MAY 1974 before ae,
a Notary Public in the State of Florida.
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... . Notary PTinlic,Stc..te c, r-ic. a
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f.)1ø Inticlittire, Made this _twenty-fourth day of JUne ,
. .4. D. 19 4.9_ between_ _Seipp stian Cemetery_ kasocia_tion_
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(7 C077}07.(7ii 071 existing under the laws of the State of Florida_ , party of the
first part, and _T. II, KtePherson i 4
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7 lq 1(-ISC peril?<7 W7?i a dd PeSS is WabaS SO t Florida
of the County of Indian_ River and State of Florida , party '
of the srefmd part,
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ECiffilc,55c.th, Tlat the said party of the first part, for and in cHrsi aeration of the sum of
Twenty and no/100- - - - - - - - - - - - - - - - - - - - - - 9oziars,
in hand paid by the said part y of the second part, the receipt whereof is hereby acknowledged, t
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hath IC MiSed, released and quit-claimed, and by these presents doth remise, release and quit-claim
unto the said party of the second part, and his _____heirs and assigns forever, all the right,
title, intorest, claim and demand which the said party of the first part hath in and to the following
A. .
described lot_ x. _, piece or parcel of land, situate, lying and being in the County of
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, to-wit: Lot 14.-,
. _ Indian___Rive_r , State of _Florida_
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Black_____24__of_theSabastian___Gernetery .
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. . if..170 OMJC alai to Doti) the same together with all and singular the appurtenances there-
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i' unto belonging or in anywise appertaining, and all the estate, right, title, interest and claim what- , t
soever of the said party of the first part, either in law or equity, to the only proper use, benefit and
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behoof of the said party of the second part, his heirs and assigns forever. t ,
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3n Witin50 Eilbcrrof, t7i.e said party of the first part has caused
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I., these presents to be signed in its name by its President, and its . f
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corporate seal to be affixed, attested by its
•. the day and year above written.
(Corporate
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Seal)
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• By
President.
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Signed, Sealed and Delivered in Our Presence: .
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