HomeMy WebLinkAbout1-30-02 Deed #108
Jack or Helen Salmela
Paid by General Receipt No. Check Dated May 21, 1968 1060 Sarno Road
225.00 3 Eau Genie, Fla. 32935
List Price $ Maximum No. Burial spaces
1 ,
Discount $ — Total area in square feet Unit 1, 81k.30,
Net Paid $ 225.00 Monument permitted Lots 1,2,3
1 (Data above this line for City Record only)
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i 14--- s31) STATE OF FLORIDA 6 _-C,
OEPARTMENT OF HEALTH & REHABILITATIVE SERVICES
VITAL STATISTICS /`
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Helen Florschutz Sa]mela DEATH August 1, 1988
2. Place of Death City, Town or Location Name of (If neither,give street address)
County Hosp. or
Brevard Melbourne Inst. 1060 Sarno Road
3. Name of Medical ' Physician Address Ph
Certifier Kenneth S. Graff, M.D. 200 E. Sheridan Rd. Melbourne, ri..1 er
Medical Examiner . Melbourne,
4. Funeral Home/ Name Address Phone Number (Area Code)
Direct Disposer Brownlie & Maxwell Funeral Horne, 1010 E. Palmetto Avenue, Melbourne, FL 32901
5. Check a ❑ The medical certification has been
completed and signed.A completed certificate of death accompanies
Appro- P s
P this
priate Dr, Graff's office 8/1/88
Box b was contacted on 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 he will complete
/ and sign the medical certification of cause of death.
was contacted on . He/she verified that
V.
, Medical Examiner, will complete and sign the
-, ,,_ ,1 medical certification.
p`.�o•- 596 August 2, 1988
6. Funeral Director/ Signature Fla. Lic. No./Reg. No. Date Signed
Direct Disposer
B. BURIAL—TRANSIT PERMIT
Permission is hereb Permit No. 499C1O
y granted to dispose of this body.
(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 t•- /.cal Re . trar of the County in which death occurred.
❑ No extension of time for Mint t.= de th cer re ed.
Registrar or /// Date 8/2/88 Date Certificate
Subregistrar Signature ' %r Issued: Due:
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
Sebastian Cemetery
Method of Disposition: Place of Disposition Sebastian, Florida
iEf BURIAL ❑ STORAGE Date of Disposition
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person-in-Charge )
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.
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HRS Form 326,Oct 87(Replaces May 86 edition which may be used)
(Stock Number: 5740-000-0326-2)
09/25/2015 15:59 #4832 P. 001/001
Aug E4 2011 10: 33AM HP LASERJET FAX .
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7.4.. ,,Nileawaloei
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City of SeInn IAar!
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Approved By
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STRUNK FUNERAL HOME & CREMATORY
1623 No. Central Ave.
SEBASTIAN Fl. 32958
(772) 589.1000