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Unit
Block 3 5
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Date .)f Mark-out 57J` 8
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Date of Burial 5/6 / Time
Name of Funeral Home / 0 T ri N 67 g rz 4 .50"1
Authorized by
DEED-1 186
Stephen & Virfinia Leichman
Paid by General Receipt .No. 57 Dated 11-10-72 Roseland Rd. (P.0. Box 1 72)
Roseland, Fla.
List Price $......150∎'y n 0 . Maximum No. Burial spaces ....22nd house on left between Rt. 1
and RR. 589-5540
Discount %
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$150.00 Monument permitted .. "" //, '
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STATE OF FLORIDA '� 3/` ''2
IDARTMENT OF HEALTH & REHABILITA SERVICES f'" 3
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT Z/ X
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Virginia Leichaan DEATH May 2, 1986
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Palm Beach Lake Worth Inst. Doctoits Hospital
3. Name of Medical JPhysician Address
Certifier Dr. Leland Heller, ❑Medical Examiner 6801 Lake Worth Rd. #219 Lake Worth Fla
4. Funeral Home/ Name Address
DIcPottinger & Son Funeral Home 1200 S. Indian River Dr. Sebastian Florida 32958
5. Check a E The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ❑
Box was contacted on . He/she verified that
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.
ic ❑ was contacted on . He/she verified that
/ , Medical Examiner, will complete and sign the
„,,1414 me al certification. 2558 May 3, 1986
6. Fur era ire tor . Signature Fla. Lic. No./Reg. No. Date Signed
xtxx
B. BURIAL—TRANSIT PERMIT X5-7-666
Permit No.
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 \ n Date 6 /Y d(p
/
Sub Registrar Signature ti ., �j r.� Issued
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
Method of Disposition: Sebastian Cemetery
Place of Disposition
3 BURIAL [1] STORAGE Date of Disposition May 611986
El CREMATION OTHER (Specify) '
Signature of Sexton ) a���1�
Z C , t .i(srir)
or Person-in-Charge ) o� �
Deborah C. Krages, City Clerk
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.)