Loading...
HomeMy WebLinkAbout2-01-02Paid by General Receipt No. .....71 ..... .... Dated - NOVember • 16• List Price Maximum No. Burial spaces ....1....... Discount $......,........... Total area in square feet .......... Net Paid $.. , , ,5 00 ....... Monument permitted . . . . F.'1 c3 �......... , �- (Data above this line for City Record only) DEED #301 Hal T. Herbert Route 2. Box 371 Micco LOT 2, BLK 1, UNIT #2 HERBERT, HAL T. 4t.30 t 4 LQ / , Route 2, Box 371 DEEDS #300 & 301 Micco LOTS Z & 2, BLOCK 1, UNIT #2 J Lois Herbert interred in Lot 1, Blk it Unit #2 on 812817601`011) -�" ✓ y ij STATE OF FLORIDA h /a1 f (� 0 PARTMENT OF HEALTH & REHABILITAW SERVICES VITAL STATISTICS APPLICATION FOR BURIAL — TRANSIT PERMIT A. (Type or Print) 1. Name of First Middle Last DATE Month Day Year Deceased OF Hal Thomas Herbert DEATH March 31, 1983 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Indian River Roseland Inst. Sebastian River Medical Center 3. Name of Medical ® Physician Address Certifier Farhat Khawa ja, M.D. ❑ Medical Examiner Fischer's Plaza 4. Funeral Home/ Name Address Pottinger & Son Funeral Home 1200 S. Indian River Drive Sebastian Florida 32958 5. Check a ® 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 i cer at' 368 March 31, 1983 6. Funeral Director/ Signatur Fla. Lic. No. /Reg. No. Date Signed fi kklk ER B. BURIAL— TRANSIT PERMIT 759 -477 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 Date �o Sub - Registrar Signature , .�,, i�� ��f sued��1L �2 "<4 �� 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: © BURIAL [3 STORAGE CREMATION OOTHER (Specify) Signature of Sexton ► or Person -in- Charge ► r Place of Disposition Date of Disposition. Sebastian Cemetery April 2, 1983 Deborah C. K CZer 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.)