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HomeMy WebLinkAbout1-29-37 , ,-- .*". , . - /a Name iO 44 i 5 r . / r il; i: i 4,. t::. ". , 3 //,:.:5, Unit / Block P- 1 Lot ..." i Date of Mark-out 7/ 3 ,,/ , Date of Burial _/ i t 0 Y Time /0 , •Ce/f ' CH ri '' ) Name of Funeral Home / 1 . Authorized by 1 .««1..0411 1« • ';.{p'11, .4r.,10-a r. II ( . . c - k - eV - .�- ; Y• - "« j- .- .`y ;T ;a 1 c_ • • . � .• • N ° a—. - Cx- , . «r \--'k -ice -1 C• ��t) -2 1- C J .. ,y v+ J N 1 • Y rn ' v1 i .- _ N N . A. Q 1, 2 �_ 1 C 4. a`f6 ■ cn. J �O ° Q ! 11 � • PI FLORIDA DEPARTMENT OF /—-27 J7 HEALT State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL -TRANSIT PERMIT A. (TYPE) 1. Name of First Middle Last Date Month Day Year Deceased Vollie Fertic Kline of July 27, 2004 Death 2. Place of Death City,Town or Location Name of (If neither,give street address) County ,reward West Melbourne Hosp. or 66 Westover Drive Inst. 3. Name of Medical Dr. Ruiz Address 1130 Hickory St. Phone Number Certifier nMedical Examiner nPhysician Melbourne, FL 32901 321/725-4500 4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No.(Area Code) Establishment 1010 E. Palmetto Ave. Brownlie-Maxwell Melbourne, FL 32901 0000049 321/723-2345 5. Check a. E The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b. ® Dr. Ruiz'office was contacted on MD= July 29, 2004 • He/she verified that this death was from natural causes,that there was no accident nor other external cause of death, Tian River and that Dr. Ruiz will complete and sign the medical certification of cause of death within 72 hours. )astian ietery c. Ej was contacted on He/she verified that , Medical Examiner,will complete and sign the medical certification of cause of death within 72 hours. 5. Funeral Director/ S F.E. No./Reg. No. Date Signed Direct Disposer 1948 July 29, 2004 B. BURIAL -TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 40 5C004 ®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. DNo extension of time for filing the death (tf4icate h been requested. P / .� e Registrar or r ' Date Date Certificate ` ,/!`�f e Subregistrar Signature / G.. ! v� Issued: 7/29/04 Due: l 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 Sebastain Cemetery Method of Disposition: Place of Disposition Sebastian,, /Florida ©BURIAL STORAGE Date of Disposition 5/O 2/4 �{ CREMATION DOTHER(Specify) Signature of Sexton or Person-in-Charge } / • 6,697 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 Nithin 10 days to the local County Health Department in the county where disposition occurred. Distribution: white: Cemetery or Crematory )H 326,8/97(Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer Stock Number 5740-000-0326-2) Pink Local Registrar 1 BROWNLIE-MAXWELL FUNERAL HOME PA 1010 EAST PALMETTO AVENUE MELBOURNE, FLORIDA 32901 INTERMENT ORDER FD In charge: Mike Phone(321)723-2345 Alternate(321)723-3167 NAME OF DECEASED: Vollie Fertic Yates Kline DATE OF BIRTH: May 16, 1915 DATE OF DEATH: July 27, 2004 SS#: 265-42-1870 AGE: 89 NEXT OF KIN: Florizell Canada RELATIONSHIP: daughter ADDRESS: 2691 Phillips Rd., Christmas, FL 32709 PHONE: 407-568-4988 OTHER PHONE: CEMETERY: Sebastian Cemetery DESCRIPTION: Unit 1, Bik 29, Lot 37 Please call if the description is blank or not correct DATE&HOUR OF SERVICE: Mon Aug 2nd ia 10:00am KIND OF SERVICE: Funeral PLACE OF SERVICE: Brownlie&Maxwell Chapel OUTER CONTAINER: Atlas Topseal CASKET PACE, Silvertone, 20ga, NON SLR, crepe int. THIS IS NOTIFICATION TO THE CEMETERY FOR INTERMENT. PLESE CALL OUR OFFICE TO VERIFY THIS INFORMATION WAS RECEIVED AND IS CORRECT WITH YOUR RECORDS. A COMPLETE SET UP IS ALWAYS REQUIRED. T0 'd WC 017: 0T beOZ-6Z- lff ctrc OF min s en 0 ,..A& - --- ---.-:---:, --- igq-9) t, ~ HOME OF PELICAN ISLAND 1225 Main Street, Sebastian, Fl 32958 Telephone (772)589-5330 - Fax (772)589-5570 August 16, 2004 Brownlie-Maxwell Funeral Home 1010 E. Palmetto Avenue Melbourne, Fl 32901 Re: Vollie Fertic Kline Gentlemen: Just a reminder that we have not received the $75.00 Opening and Closing fees for the interment of Mrs. Kline at the City of Sebastian Cemetery on August 2, 2004. I am enclosing a self- addressed envelope for your convenience. Please remit this fee as soon as possible. I am also sending you a copy of the prices, service fees and rules and regulations governing the cemetery. Thank you for your cooperation in this matter and if you have any questions, please contact our office. Sin ely, / // 6.3)7/ _L.—, Sally A. aio, CMC City Clerk SAM/ar Enclosure lotsaleletter CITY OF SEBASTIAN CITY CLERK'S OFFICE 3 0 7 9 RECEIPT Nanhi11-4-4-et— 4e#. - -Lf-/ 0 Cash Date L4 /.;-, No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies/Bid Specs. 001501 341910 LDC/Code of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots Lot/Niche Block ,Unit 001501 343805 Cemetery Fees ,--F757e)e zii- z5,27- .637 (Thil )27"-- ;-----,,, Total Paid /7e- '-4"1-2 Initials White-Dept.of On in• Yellow-Finance •Pink.Applicant / '4°." / ----------- ----------- . .' \ '.*----- -4 ....( • -L tN t.3 Cs.--' t -.. \ , "t. k.a ..., 4, ,,,1 \i -, • -1, \ .,.:-. I \j`. -..< ■,,) ' ' . itli c... "\ U . • ,.. '-... \ •5 t: ,:. ---1 ' 1--- -1.- . - -( -._: - k '.1 tli 0-,3-- , ' • .-., ..... , , ''•■cr ' •A- .. ` c- 1,) .1, '‘ , k '-', k . - „