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Home My WebLink About1-08-03 Name Unit Block Lot Date of Mark-out / Date of Burial e" C Time Name of Funeral Home. -; Authorized by e, /, FEB-13-2001 TUE 04: 17 PM WASHINGTON CO. HEALTH DE FAX NO. 4239752210 P. 01 FEB-13-01 TUE 04:23 PM M01110 — BAKER FAX:423 282 4064110 PAGE 1 L3 TENNESSEE DEPARTMENT OF HEALTH ,43 W ' ' OFFICE OF VITAL RECORDS • ra u4 PERMIT FOR FINAL DISPOSITION OF HUMAN REMAINS ( ! / ( zrE�ixy Name of Decedent Sex Date of Birth Date of Death Ramona Vickers _January 5, 1929 ?ate 19, 2001 Place of Death City or Town,County Name of Informant iii Johnson City, Washington County, Tennessee Mr, Jack Vickers • Name of Funeral Director(or Person Acting as Such) Name of Attending Physician Robert L. Odom - Dr:. David C. Tabor Address of Funeral Director(or Person Acting as Such) 2001 Oakland Ave., Johnson city TN 37601- I hereby apply for a permit for the-final disposition•orihe remains of the Bove named decedent.I agree to abideby all laws and rules of-the Tennesseeflepartment.of Health and.all.otheriaws.pertainingtothe.-.,.,.. Application preparation,container,transportation,burial and/or cremation of the same. The type permit needed is checked for Permit below, If I have not been able to submit a properly completed certificate of death for this person at the time of this application,I agree to file within three days the required record with the local registrar in the county whe;,l; e death occulted./ 2001 Oakland Avenue si O/'-4at Address w a• OF PERMIT REQUESTED(Check all that are applicable) ( Burial Q Cremation ()Disinterment 0 Transit C) Scientific Use - Q Reinterment Name and Address of Cemetery where Remains are to be Interred Burial Sebastian Cemetery, Sebastian, FL Name and Address of Crematory where Remains are to be Cremated Cremation 'tom To Transit Johnson City, TN Sebastian, FL Disinterment Removed From(Name and Address of Cemetery) Place of Reintcrrnent(Name and Address of Cemetery) Reinterment Scientific Use Name and Address of Facility Receiving Remains • I consent to the issuance of the Permit for Final Disposition. Physician or Medical Examiner signature of Attending Physician or Medical Examiner* Address ''Authorization of the Medical Examiner is required for a cremation permit. This permit for the final disposition of the remains of the above named is granted for the purpose(s)checked above. Permit of • Local Register ti/ el:./ 1 Signature of local Registrar 7e2 h es (2t• arc is'l.2 3_244• '5L I certify that the di ition of the remains of the above named was made in accordance tii this permit on ° at . S�/�M77,-1 iZ ��i-711f1P;7/6-47-27 Certification of Date Place Person in Charge • of Disposition signature • / I . '. Address //D// �� /r/ )//c e S PH-1687(Rev,8/97) RDA 1468 i i t 1 —5 —6.V\ z 0 4. .,:s' ` - d K -F Cti1 " ) •-V • 'V 1° 1 W �� (11 W l/, ZO(' • v `S Z \V� c-T\ W N v . o :..fi 4 -35 cam` •'V /'' • A • • S, sz-' Z ■ .i C. _ (� u itS _.. — . ,�+ s. T —s. f _— —-- :.G — ...._ "'...... Y • JUL-18;2012 WED 11 : 15 AM MCB Bristol Highway FAX No. 423 232 5134 P. 003/005 From:The UPS Store 4239 7725899175 07/17/2012 10:56 #500 P.002/007 e_D . 4iniDi ono N HOME OF INUCAN IStANO Burial rights in the Sebastian Municipal Cemetery lots/niches purchased by me_ tGtut:, t V N4.:14(S I ( 7 . ./d r /i E �®k,SON c 1 t (Please print name and address of purchaser) -t' 1 1 6.0 I (Lot/niche,block, unit description) are intended for interment of the following individuals: Please print name(s): t r q (7) L (6) V; 2rs F19-1— (11 ) VIGs-2� ?4 - (2) ?(3y 1-,c,,,a, gld-ers (7) ae C'3.6 V/t-",.,.erg (12) 1_;Irei'''6+4 Vic;fke—s (3) ( k-c1 on V't GK.•zr-5 (a) SPrr-ck V�c 4.-5 (13) 1 i/t c.Aty5 (14) • ' (' (4)��cam-- � i ��_5 (g) 1/'L�•�"5 ,lr)-1--- (5) i,c k-ers etJ - (10) altAgn V}'r�k4f--. (15)yci-'r5 pio - Interment lots/niches are not to be transferred without written approval of the City of Sebastian. Interment lots/niches in the Sebastian Municipal Cemetery are allowed to be passed on to heirs but the City requires a certified copy of relewint probate or other court documents, t h: - re ' d u•- - to a arms of this agreement. G% r'f• 17 - t-Z_. nature Date in4 _day or ZU 1Z by Subscribed and ew to before me this or • hue produced heLJ A V , who is personalty known to me, Ss ldentifioallort. `,`��tirrEr,,,li a .r Moiety i eat.o s � i.s. I. STATE •:�L.'� a I OF"'ortnwmo i0"n _ i r TENNESSEE t, *t: NOTARY J 'I 17-:9 PUBLIC , ' i � ,''ttt►rirrrc�c', JUL-18r2012 WED 11 : 15 AM MCB Bristol Highway FAX No. 423 232 5134 P. 004/005 From:The UPS Store 4239 7725899175 07/17/2012 10:56 #500 P.003/007 ona SEBASTIAN NOME Of PELICAN MVO A Buri I rights in the,Sebastian Municipal Cemetery lots/niches purchased by me ;c6 4 E U(ch4(5 ( (.c !vJter )4100- . 11,..0, C:rc1 TIJ 3 W/ (Please print name and address of purchaser) (Lot/niche,block, unit description) are intended for interment of the following individuals: Please print name(s): ,! ��47 V iC.k'2i l0 ($6 ")T e.te-e.,5 0, -(-- (764)- o.. c=-n .irc".3-3-) V 1 . p)o4-- 1) 0.tIn Vi c .r5 6°i ...- (f ) AA- r.P 7)6,38,-) Vrci1 p1o4-- P'')0 -otr ■Oc-x-ers )44) PW(5 ),gin !PYr 477)0-11r8a Uavri)As tr;c,k. , (062V)r L(9 1- V IL&r (7 (X,..7/ 1 \ '(1 l.k`urJ �� +`C�V)3k/91 1U) C vI ,,5 ue. interment lots/niches are not to be transferred without written approval of the City of Sebastian. Interment lots/niches in the Sebastian Municipal Cemetery are allowed to be passed on to heirs but the City requires a certified copy of relevant probate or other court documents. I 1)- -_.d = •• •e t •, e terms of this agreement, -7 ( '2 --I'L Signature Date ubsrr ed and sworn b before me this day of Q ___.. �� by diy who iq -r�red 1� 'i��kr own me. or hos produced as Identil` Y'... <<C`'1i Nubbly Public.§tah ol-Elorida fit. s. i Fit OR F •n Ai 4,04'4 ic= Names of Intarre0 form S f2 A4 ttlit,F; • • O... <'c . "' co '''I!ff►ttttt<<''` JUL-18;2012 WED 11 : 15 AM MCB Bristol Highway FAX No. 423 232 5134 V. UUS/UU5 From:The UPS Store 4239 7725899175 07/17/2012 10:57 #500 P.004/007 . (. ) attar SEBASTIAN NOME OF MEUCAN ISLAND Burial rights in the bastion Municipal Cemetery lots/niches purchased by me E� E c S i s— T't,ucr ridQF ,yam irw6od 0,17c( Trr (Please print name and address of purchaser) 3 1 '8ce F5 C3,,-,A-- 1 (Lot/niche,block, unit description) are intended for interment of the following Individuals: Please print name(s): - ( / iI61,-,w1 • id -s (' 3(A Lei t,, '. 41 i I. ' (11 ) ( . 'c., • - c-i- (7/ i-;1 S n ' (12) Y (33� V 1 ci�rs V o-t- (7 i L4 S \ p)D--, (la) (e1 (2)`)YAGVser- p'°4 (y1( xsa-, p1.04/ (14) (f (- V t Cj f 5 t it.n- 901 C`/3. L.pyt,:s io Ji,--1- (16) Interment lots/niches are not to be transferred without written approval of the City of Sebastian. interment lots/niches in the Sebastian Municipal Cemetery are allowed to be passed on to heirs but the City requires a certified copy of relevant probate or other court documents. I have d and 4.rst d the terms of this agreement. 7 Date t r by SVbse`b.d to berera me This day ef �� . `� ,, r has pmducad who is personally kn`pl , 3.1 Cat.. �t S a.1 t e'tty S. as Identification_ _Q...•.--"..•776-,,,, 0,4 Nolary Public,Slate of Merida '(� _ H N c Mamas of Wawa term ti; e4Y •7f i, ( c _ `D /-,f11llltli ,-