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• lcek 30 Lot 27
- Unit
Hems Mrs. 1'►1 a x i e
a G!3
e4.^..s7 /'/4-
INTERRED 8/14/85
Name \ 3 'kaX► NA
Unit
Block 3 0
Lot al
l
Date of Mark-out 1 - d5
Date of Burial F- I 1 - F5 Time 11 : 0 0 11-.61
Name of Funeral Home (7 )e 61 F FQ/Q. Q Fam g /Q!9 L 1q b Ivt
Authorized by
Deed # 157
Paid by General Receipt No. 146 & Ck.(Bk.�ated 12/8/70 Mrs, Maxie Nam ,,/ ��L���4rQ -
List Price 250.00 Maximum No. Burial spaces 1 i��' a. "'
Fla.
Discount $ — Total area in square feet
Net Paid $...250.00 Monument permitted flat Lot 27, Blk.30
Unit #1
(Data above this line for City Record only)
STATE OF FLORIDA
RTMENT OF HEALTH & REHABILITATWSERVICES 4 7 '.- 6/
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Mamie Ham DEATH
August 11 . 1985
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Inst.
Indian River VerQ_B_ea • • •'• • :' - u 11 • •. • . .
3. Name of Medical ❑ Physician Address
Certifier Leonard 1 al er M.D. Medical Examiner P.O. Box 188, Ft, Pierce, Florida
4. Funeral Home/ Name Address
D7 X.Rj 3E .XXX Cox-Gifford Funeral Home,t95.O_2dth St. , Vero BQarh Fla.
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ❑ was contacted on . He/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
will complete and sign the medical certification of
cause of death.
c ® Dr. Walker was contacted on 8/12/85 . He/she verified that
he , Medical Examiner, will complete and sign the
medical certification.
6. Funeral Director/ Signat Fla. Lic. No./Reg. No. Date Signed
XIYIAMIXISdkXr
R. Marshall Voyles Jr. .� ....�� • _ 228.3 Augers+ f. 2„ 1885
B. BURT -TRANSIT PERMIT
Permit No. 1423-201-1985
Permission is hereby 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. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or o�, �5+ � Date August 12, 1985
Sub-Registrar Signature ✓.a. . / Issued
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL-AT-SEA
Signature , Medical Examiner Date.
or
Medical Examiner, , gave authori,ation 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 Sebastian Cemetery
UJ BURIAL ❑ STORAGE Date of Disposition August 14, 1 985
CREMATION El OTHER (Specify)
Signature of Sexton )
or Person-in-Charge )
Deborah C. Krages, CfEJ C1er
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.
HRS Form 326, APR. 81
(replaces previous editions which may he used.)