HomeMy WebLinkAbout2-13-07Paid by General Receipt No. ...... 1.89.. ... .... Dated... M4Y..7,J9AQ
List Price $. ,200,.00 .......
Discount $.... 7
Net Paid $, 200.00
?&R attached
Maximum No. Burial spaces ........2...
Total area In square fact ................
Monument permitted ..... FZ at:......... .
DEED
Mrs. - Lewis Waters (Nancy) #398
(Russell Street, Roseland)
P.O. Box 801
Sebastian, Fl 32958
BLK 13, Lots 6 & 7 Unit 2
Lewis Waters interred 515180
(Data above this line for City Record only)
R A TING
DEPARTMENT OF 11EAL11-1 AND REHAHILIIATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL - TRP,__.iIT PERMIT
�7 X13 // C
NAME OF First IMIS
Middle MALLIE Last
DATE Month Day Year
Type Aor print) Mallie
Lewis Waters
OF
IDEATHAPril 0 80
PLACE OF DEATH
CITY, TOWN, OR LOCATION
NAME OF
(If not in hospital, give street address)
couNTYlndian River
Sebastian
INSTITUTION Delaware & Georgia Blvd•
Attending Physician 11
(Name of Medical Certifier)
(Address)
Medical Examiners Ex H.L. Schofield, Jr. M.D. 1503 24th Street
Vero Beach Florida 32960.
Funeral (Name)
(Address)
Home Colonial Funeral Home S. Indian River Drive Sebastian
Florida 32958
Check A ff A completed certificate of death accompanies this application.
One
B ❑ Dr. was contacted on 19
He has assured me that this death was from natural causes and that he will complete and sign the medical
certification of cause of death.
C ❑ The attending physician was unavailable or this death comes within the Medical Examiners jurisdiction.
The body was released to me by
on ,19
1579 May 1. 1980
(Signature) i (Fla. Lic. No.) (Date Signed)
Funeral
Director
BURIAL TRANSIT PERMIT No. /1 9 — , /7/0
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For cremation a
waiting period of 48 hours after death must be observed and the Medical Examiner's approval must also be obtained.
❑ A five day extension of time for filing the death certificate has been requested and granted.
Signature of Date
Registrar i i !, Issued
Method of Disposition
Signature of Swcien
or Person in Charge
CEMETERY OR CREMATORY
Date of
Disposition May 198n
Place of
Disposition
Sebastian Florida
This permit must be endorsed by the sexton or person in charge (or by the funeral director when there is no sexton) and returned
within 10 days to the local county health department.
HRS Form 326 (1177)
BURIAL
L. I
CREMATION
(�
STORAGE
L]
OTHER(Specify)
Signature of Swcien
or Person in Charge
CEMETERY OR CREMATORY
Date of
Disposition May 198n
Place of
Disposition
Sebastian Florida
This permit must be endorsed by the sexton or person in charge (or by the funeral director when there is no sexton) and returned
within 10 days to the local county health department.
HRS Form 326 (1177)