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UNIT NUMBER
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BLOCK
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LOT\NICHE
103 <fo Y
lOT\NICHE
Owner
o ccupant( s)
Deed
I
D ele!e
LastN<1O'1e:IT albot First MI: (Renee A.
Address;l6360 River Run Drive,
IBldg D-2
City: IS ebastian S tate/Prov: I FL
Zip: 132958
Phone: I ( J -
Fax: I ( J
Res.iclent P
Notes:
Ext: I
SSN: I --
? Help
.
~~ Advice
Pers()nallnfo' I nfor m ant Contact 1 Contact 2 User Defined Fields
Owner
Editing
Owner: Talbot, Renee A.
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Name
Unit
BloCk
Lot
Date of Mark-out
Date of Burial
01
~"',,,...,.
Name of Funeral Home
Authorized by
.';~ "
Time
a
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A.
1. Name of
Deceased
(Type or Print)
First
Edward
Middle
J,
Last
Talbot
DATE Month
OF
DEATH October
L~
'J
13 ;2 :1
if /7
Day Year
9, 1998
I~
State of Florida, Deparbnent of Health, Vital Statistics
APPLlC. FOR BURIAL - TRANSIT PERMIT
.
2. Place of Death
County
Indian River
3. Name of Medical
Certifier Curtis Oalili
City, Town or Location
Vero Beach
Name of (If neither, give street address)
Hosp. or
Inst. I ndian River Memorial Hospital
W Medical Examiner
~Ph .. 2208 8th,
~-'" YSlclan
Address
1623 N. Central Avenue
Sebastian, Fla. 32958 1228 561-589-1000
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
Phone Number
561-567-433(
Avenue, Vero Beach, Fla, 32960
Address
4. Name of Funeral Home/
Direct Disposer
Strunk Funeral Home
Fla, Lic. No.1 Reg. No. Phone Number (Area Code)
5. Check
Appro-
priate
Box
a 0
b~
was contacted on 1 0 / 09 / 98 within 72
hours after death. He/she verified that this death was from natural causes, that there was no accident
nor other external cause of death, and that He will complete
and sign the medical certification of cause of death.
Dr, Oalili
c 0
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
medical certification.
6. Place of Sebastian
Final Disposition:
7. Funeral Director /
Direct Disposer
Fla
.E. No.1 Reg. No.
Removal
from state Donation
Date Signed
10/10/98
B.
BURIAL - TRANSIT PERMIT
Permit No. 1228-98-435
Permission is hereby granted to dispose of this body.
o A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit. If the certific;ate cannot be filed within this extended time limit, a "Funeral Director/Direct
Disposer Report" will be filed with the Local Registrar of the County in which death occu-rred. - - - -
o No extension of time for filing the death certificate requested,
nS€liatfar sr .
Subregistrar Signature
Date
Issued:
10/10/98
Date Certificate
Due:
C.
AUTHORIZATION for CREMATION, DISSECTION or BURIAL-AT-SEA
Signature
or
Medical Examiner,
, Medical Examiner
Date
, gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of ~he above methods. A waiting period of 48 hours after
death is required for all cremations.
D.
CEMETERY OR CREMATORY
Methods of Disposition:
W. BURIAL
o CREMATION
o STORAGE
o OTHER (Specify)
Place of Disposition
Date of Disposition
...t~.vJ~ ~:&'1
CJ~ I~I /118
Signature of Sexton )
or Person-in-Charge )
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1
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This permit must be endorsed by the Secton 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.
DH 326, 10/96 (Replaces HRS Form 326 which may be used)
(Stock Number: 5740-000-0326-2)