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STATE OF FLORIDA
ARTMENT OF HEALTH & REHABILITA* SERVICES �' /►` T
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Marslena Ruth Royal DEATH June 8. 1982
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Broward Ft. Lauderdale .Inst. North Beach Medical Center
3. Name of Medical B15hysician -Al �s � d.
"' Certifier 400 `ke_octc ksj� Medical ExaminerI4S3®W _:J9_ yp J+
4. Funeral Home/ Name Address
Direct Disposer Strunk Funeral Home 734 N. Central Avenue, Sebastian. Florida 32958
5. Check
Appro-
priate
Box
6. Funeral Di
Direct Disc
a The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b ❑ 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.
c ❑ was contacted on . He /she verified that
Medical. Examiner, will complete and sign the
medical certification.
Fla. Lic. No. /Reg. No. Date Signed
BURIAL — TRANSIT PERMIT Permit No.1228 -037
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 }his time limit, a "Funeral Director /Direct Disposer Report" will be filed
with the Local Registrar of the Coun in which death occurred.
Registrar or
Sub- Registrar
G
Date June 9, 1982
Issued
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature
or
, Medical Examiner Date
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.
CEMETERY OR CREMATORY
Method of Disposition:
fi4BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature Sexton
or Person -in - Charge„)
This permit must be enrsed by the Sexton or person -
and returned within 10 days to the local County Health I
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
Place of Disposition `,tbPrST+�I►.J�.
Date of Disposition
(or by the Funeral Director /Direct Disposer when there is no Sexton)
it in the County where disposition occurred.