HomeMy WebLinkAbout1-35-27 Block 35 Lots 27, 28 Unit 1
rice, Charles G. Deed #203
Tice, Mrs. Ilelcn rF='t r=
312 Pineapple Street
Sebastian, Fla.
Charles Tice interred Lot 27 on 5 /17 /84
152 April 24, 1973 Deed # 203
Paid by General Receipt No. Dated
Charles G. and
150.00 ' ) 2 Irene M. Tice
List Price $ Maximum No. Burial spaces
Discount $ Total area in square feet 312 Pineapple St.
Net Paid $ 150.00 (ck) Monument permitted Flat Sebastian
blk 35, lots 27 & 28, unit 1
(Data above this line for City Record only)
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STATE OF FLORIDA e � x, -?c) 6 7
4,PARTMENT OF HEALTH & REHABILITlE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Charles Godfrey Tice DEATH May 15, 1984
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Sebastian Inst. 312 Pineapple St.
3. Name of Medical Xi Physician Address
CertifieRobert Moore, M.D. 0 Medical Examiner 2045 15 th Avenue Vero Beach. Fla. 32'.
4. Funeral Home/ Name Address
9 J Pottinger & Son Funeral Howe 1200 S. Indian River Dr. Sebastian Florida 32958
5. Check a La 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 ❑ was contacted on . He/she verified that
Medical Examiner, will complete and sign the
e cer—tifTicatiou.
a 4v?, 4, lam; /),esi
6. Funeral Dir or/ Sigr ure Fla. Lic. No./Reg. No. Date Signed
B. BURIAL—TRANSIT PERMIT M
Permit No. 719 '`�J'.8
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 Date
Sub Registrar Signature Issued //
/4111111r
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
Med d of Disposition: Sebastian Cemetery
K Place of Disposition
BURIAL ❑ STORAGE Date of Disposition May 15, 1984
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton
.,)J3 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 Co my where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
MEMO
•
0 .- /1� ;/J 0 Marty
M
SUBJECT DATE
Unit 1, Block 35, Lots 27 & 28 5/15/84
iiPottinger called and would like Lot #27 prepared for Thursday morning.
iThis is for Charles G. Tice.
lr
SIGNATURE
T DATE
,. ) 1 J
i
AICO-UTILITY FORM NO. 45002 SIGNATURE PRINTED IN U S A
I DETACH AND RETAIN THIS PART FOR FOLLOW UP