HomeMy WebLinkAbout1-34-32 STATE OF FLORIDA
PARTMENT OF HEALTH & REHABILIT•E SERVICES
VITAL ���
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Stella Marion Wiszniowski OF Nov. 25, 1984
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Dade Miami Beach Inst. 34 Collins Ave. # 1
• 3. Name of Medical [' Physician Address
Certifier Stephen R. Blair, M.D. nMedical Examiner 1050 N.W. 19th St. Miami, Fla.
4. Funeral Home/ Name Address
MkamANgmet Pottinger & Son Funeral Home 1200 S. Indian River Dr. Sebastian Fla. 32958
5. Check a Epx The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b 0 was contacted on . He/she verified that
Box this death was from natural causes, that there was no accident nor other external ca'rse of death, and that
will complete and sign the medical certification of
cause of death.
c El was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
41E16 oied' ti •
. � ,�ly%: � ''f "2368 November 27, 1984
6. Funeral Director/ Signature / 1111 Fla. Lic. No./Reg. No. Date Signed
xtitcceotbigioxerocx
B. BURIAL—TRANSIT PERMIT 759-578
Permit No.
Permission is hereby granted to dispose of this body.
requested five day extension of time for filing the death certificate (exclusive of weekends) has b een ey uested 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 Date �y� q�
Sub Registrar Signature �; ��- R64 -�� Issued l�� '
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
•
• Signature , Medical b,*arniner 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 .
Method of Disposition: Place of Disposition Sebastian Cemetery
1 BURIAL ❑ STORAGE Date of Disposition. November 29, 1984
0 CREMATION 0 OTHER (Specify) '
Signature of Sexton 1 1
or Person-in-Charge ) .C,. . u,L ..
1
Deborah C. Krages, Ci - lerk
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 be used.)
_.—__.�G�J r ( / Co..A 4,•�TERMS -___
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Paid by CEMETERY Receipt No 39_2
Dated November 28 , 1984
List Price$ 300 . 00
NO.
Maximum No.Purial Spaces 2
300 . 00
Net Paid$ Flat 1 6J'-� 0
Monument permitted
Lots 31 & 32 , Eryk WISZ$Iowski
Block
#34 , Unit #1 591 Wimbrow Drive
(Data above this line for City Record only) Sebastian, Florida 329 5 8
BLOCK 34 LOTS 31 & 32 UNIT 1 DEED #1030
Eryk Wisz/4owski
591 Wimbrow Drive
Sebastian , Florida 32958
Stella Wiszdiowski interred 11 /29 /84
ill!
•
THE SEBASTIAN CEMETERY 311
City of Sebastian
Sebastian, Florida
RECEIPT IS HEREBY ACKNOWLEDGED OF THE SUM OF:
11- t - ALI in n o.D u� i G o Dollars (S 300 .00 )
FROM: C.L4 )3 1 S V N ci iii
s `) m\IIRUUD
EA,cis\C lc-ALI 1.a.
on this '42 day of AJ p v. , 19 Pyfor the purchase of the following
described Cemetery Lot(s) upon the terms and conditions as stated herein:
Description of Property:
Cemetery Lot(s)# Block# Unit# /
Purchase Price \}O1 ,, VV.A Line{D j Op Dollars($ 4'O O . Qt) )
Terms and conditions of sale:
' This contract shall be binding upon both parties, the seller and the purchaser, when
approved by the owner of the property above described.
I, or we, agree to purchase the above described property on the ter and conditions
atatad in the foragoi ng in rtrwmwant t
/ 0.04P
The City of Sebastian agrees to sell the above mentioned property to the above named
purchaser(s) on the terms and conditions stated in the above instrument.
L.
City of Seba ian
tness