HomeMy WebLinkAbout1-30-11 - - - - -
Name ik--)1.1 ") 04- -e''V*1 LA( 1161U
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Unit
Block
Lot '
„ 7Date of Mark-out
Date of Burial Time /0 oe)
Name of Funeral Home
Authorized by
■ ■ ■ IMO ■ MIN ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
TO replace cancelled deed #135 Deed #142 (mailed 3/17/70,
Paid by General Receipt No. Dated 11/14/69 Rudolph W. Long
Foster Rd.
List Price $ Maximum No. Burial spaces Sebastian, Fla.
Discount $ Total area in square feet
Net Paid $ **50.00** Monument permitted Lot 11, Blk. 30
Unit rl
(Data above this line for City Record only)
Block 30 Lot 11 Unit 1
Long, Rudolf Deed #142
Foster Road
Sebastian, Fla.
Interred 6/7/87 (Cremains)
LONG, Rudolf
Deed #142
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UNIT 1, Block 30, Lot 11
Interred 6/7/87 (Cremains)
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Block 30 Lot. 11 Unit 1
Long, R,adolf Deed #112
Foster Road
Sebastian, Fla.
Interred 6/7/87 (Cremains)
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_ _ M S DAYS ( H 'JR= MINE
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. CITY TOWN OP LOC A.T.,D'.Dr.DEATr IHOSPITA.OR OTHER INET ITUT1...-.,, u,r n,,.,. er.ne' c:✓e roe• an^,,,,e I I1 HOSE OF,INS-, Ilno,ca:r DOA.
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0 STATE OF BIRTH tit no,tr 1 CITIZEN OF WHAT COUNTRY ImARRIED NEW-IF 6JARRIEC I SURVIJING SPOUSE/l:cne prre mace-,name:
U.S.A. name country: IWIDOWED DIVORCE::CSpecriy:
E rcnrgvlVanir"? 1 T'_S_A. bc,NPlPr L `rie(i 111
I SOCIAL SECURITY NUMBER i USUAL OCCUPATION lure am:of Wort pone durmf (KIND OF BUSINESS OR INDUSTRY
moss co War6,nc lire ever.:,I retired:
12 1 6n-78-. frL(o u Postma_ t r_ rot. mt U.S. Government
RESIDENCE-STATE I COUNTY - CITY.TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMITS
14 _ 1 ,..(Specify Yes o'No;
\1It Fi eri d- )14L Tyr-r_']'ar.C? 1a: ki 1 ni rria lae ]411 5 S . Hi ckory Street Yes
t / FATHER-NAME FIRS- MIDDLE LAS- 1 MDTHEF-MAIDEN NAME FIRS' MIDDLE LAST
1,
(T}POhtai P_bj - i1E (Unobtainable)
'INFORMANT-NAME/Tape o:Fr,nl. II MAILING ADDRESS STREET OP R E D NO CITY OR TOWN STATE ZIP
II° 176 TiPtry Flits 117E 1X.01 N. GPntral 'venue y Sebastian. FL. 32958
• BURIAL CREMATION.REMOVAL OTHER;Soecily! )CEMETERY OR CREMATORY-NAME I LOCATIOn CITY OR TOWN STATE
1 Esaz
r ,BE C:re
Trari nn 1t8, Fountai shear' 118c Palm Bay, Florida
0 FUNERA',-W'BECT4F-n "'
5 ..6:ur�- - I FUNERA'_HOME ADDRESS ----__
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/ /EL 19a i // /•_G- � 1 l sEFPS m'a i n,aad F rat Tme P.O.BB k0369 Pa. Bay. Florida 32935-03.69
C .QOa l0 the bes:of mr knowledge craft) ai the IIm5,dale ant place and due 21a On the basis of examination and/or investigation.In my opinion death occurred a:the
It, J tO the causelsl)stall �� / / 1���� .t., time date and place and due to the cause(s) stated
s m (Signature and Title) {\N. `/\ ' ? (S:Er,.ture and Tttle)►
-°4„ DATE SIGNED(Mc. Day.Yr.; J HOJ�OF DEATH �x DATE SIGNED(Ma. Day. FL) (HOUR OF DEATH
c`O nOO ` {� n cW
O; 20c Nab' 76 }95.2_L—. 7U. _ - S�s10 A.M i D� 2,c _ 21c y
`� NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER(7yot or Fnnt, 21.D PRONOUNCED DEAD(Mc. Day. Yr., PRONOUNCED DEAD(Hour:
f C -W
-- W. 2
U 2C/t ?1C ON 21e AT M
w - —N41,1_ANC ADORE SS OF CERTIFIER Fi IPF?VSICIAN ME DICAL EyRIJ,INERi liype or print) ---- - ------ - -- - -- --
z2 W.S. Sanford, Fi.D. , 1281 S. Hickory Street, Melbourne, Florida 32901
n..a■S RAF /I y LATE RECEIVED BY REGISTRAR(Mc.Day 11.F
.a� 's o,,a ►��..r� / -%/ /- ∎/ -, it . , .�,:. ,_� � )(2., :� S /� I i i 73L 0 / / r? -!
/2' IMMEDIATE'CAUSE If N7 H ONLY ON ECAUS_PER L/N_UFOR ra, (0, AND(c).j I irterva netween once,ane orate
I PART fa 1
I I _- Acute Myocardial infarction _ _ ; Four to Six Hours
DUE TO.OR AS A CONSEQUENCE OF (Condtion(s)which care rise td case(a)-Lst undeiymg cause last] )Imervar botweer arse'and pear
lb! Generalized Arteriosclerosis iYears
. DUE TO OR AS A CONSEQUENCE OF )Inters'between ems- anc orate
24 - c. Senile Dementia ; Years
C FART OTHER SIGNIFICANT CONDITIONS-C,,,,,,,,Col.,:,,,,,.-to oa.'cu me rrae:to case D-r.,r.PART I(a, FART III IF FEMA_E WAS THERE A AUTOPSY CASE REFERRED IC MEDIC&
_I li PREGNANCY IN THE PAST 3 MONTHS, iyes a no, EXAMINER,Sseeny yes a ro'
27t--------'---- ; Yes r: No C 25 No 26 No
IProcahyl ACCIDENT SUICIDE or GATE OE INJURY(Mc.,Day,Yr.) HOUR OF INJURY DESCRIBE HOVE INJURY OCCURRED
-7 HOMICIDE or UNDETERMINED(Specify)
27g _-
27a 27C 27c M 27d
d 1.RS 'norm 512. I _- --- -- -- - - --- --- - - - - - -
INJURY AT WORN(Specify 1 PLACE OF INJUP,s'-AI home ta•m.sheet factory oft/Cc i LOCATION STREET OR R D NO CITY OR TOWN STATE
.1' Ei.4 (nosDieleS I Ye:or No' I 5.:l0i nC OIL.'Sprcrly: I
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':=1,.'1',!E Eclj;IUf15 \27E
127 127c
I HEREBY CERTIFY THE ABOVE TO BE A TRUE AND CORRECT COPY OF THE RECORD ON FILE IN THE
LOCAL REGISTRAR'S OFFICE IN THE BREVARD COUNTY HEALTH DEPARTMENT.
(Not valid unless the seal of the Brevard County Health Department is affixed.)
,9 \ 4 I J� .
Local egistrar
.
L 98
,.a UN.0 7 it _
Date 8 Seal r Chie Deputy Registrar