HomeMy WebLinkAbout1-28-01 Name ESTE LLE 4. Vic k 't
Unit
Block i
Lot.
Date of Mark-out ,'`I I 4` .1
Date of Burial ft� Time /o',DC' -.1'Y7.
Name of Funeral Home .�1 L'kT 1 v'k+ ats4kt,
Authorized by_ '
Block 28 Lots 1, 2 Unit 1
Vickers, Estelle Deed. #205
Vickers, Frank (Interred)
Box 28, Minton's Corner Trailer Park
West Melbourne, Fla.
toldIe 0e14-ers- 'in1-erred Lejtglg3, Lot I
SUPERSEDES l6ee Deed •62 ' ; Frank C. & Estelle
•a e. an. •, ••1
April 25, 1973 �_� _ , . Vickers
Paid by General Receipt No Dated
• %' Box 28, Minton's Corner
2 Trailer Park, J.melbourne
List Price $ Maximum No. Burial spaces
Discount $ Total area in square feet / NCI corner
Net Paid $ Monument permitted Flat only l�
Lots & -
block 28 JJ
(Data above this line for City Record only) � .4 45-
/()
State of Florida,Departme Health and Rehabilitative Services, Vital Sacs / ,&
• APPLICATI OR BURIAL — TRANSIT PERMIT C
' A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Estelle L. Vickers DEATH June 11, 1993
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Inst.
Brevard Melbourne Holmes Regional Medical Center
3. Name of Medical I Medical Examiner Address Phone Number
Certifier 5200 Babcock St. , NE #105 (407) 728-5911
Ronald V. Trout Physician Palm Bay. Florida 32905
4. Name of Funeral Home/ Address Fla. Lic. No./Reg.No. Phone Number(Area Code)
Direct Disposer 1001 So. Hickory St.
South Brevard Funeral Home Mel bourne, FT. 32901 937 (.- 07) 724-2222
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b al T.Psl i e in Dr_ Trout'a Offi re was contacted on 06/11/93 within 72
hours after death. He/she verified that this death was from natural causes, that there was no accident
' nor other external cause of death, and that Pona 1 d V_ Trout will complete
and sign the medical certification of cause of death.
c ❑ was contacted on .He/she verified that
. Medical Examiner, will complete and sign the
medical certification.
6. Place of In state cemetery/ Sebastian Cemetery Removal
Final Disposition: crematory - name/count radian River n from state • n Donation
7. Funeral Director/ • - u^ F.E. N /Reg. No. Date Signed
Direct Disposer 5601 06/11/93
B % RIA — TRANSIT PERMIT
Permit No. 937-9893
Permission is hereby granted to dispose of this body.
Qi A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit,a "Funeral Director/Direct
Disposer Report' will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for f'ing the death c.:r'fi •to request-d.
Registrar or �4 j, / / Date Date Certificate
Subregistrar Signature�v�-- - ���4--,,,, Issued: 06/11/93 Due: 06/21/93
C. 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 all cremations.
D. CEMETERY OR CREMATORY 1552
Methods of Disposition: Place of Disposition Sebastian Cemetery
® BURIAL ❑ STORAGE Date of Disposition 06/14/93
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ) //
or Person-in-Charge) K F• '97 •
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 HRS County Public Health Unit in the County where disposition occurred.
HRS Form.326.Feb 89(Replaces Oct 87 edition which may be used)
(Stock Number:5740-000-0326-2)