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•STATE OF FLORIDA
EPARTMENT OF HEALTH & REHABILIT E SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL -- TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased
Charol Augustus Hoffman DEATH April 19, 1983
2. Place of Death City, Town or Location Name of (If neither, give street address)
CoB evard Melbourne Ins.. or Holmes Regional Medical Center
3. Name of Medical Physician Address
Certifier Kenneth Graff, M.D.
❑Medical Examiner
4. Funeral Home/ Name Address
Q+�x fottinger & 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.
6. Funeral Director/
RWAkR R9L9*Rxx
B.
MN.
was contacted on . He /she verified that
Medical Examiner, will complete and sign the
al cej I'An=
q�
� 368 April 19, 1983
Signa`lure ll' h � I— Fla. Lic. No. /Reg. No.-
BURIAL — TRANSIT PERMIT
Date Signed
759 -480
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
Sub - Registrar Signature
Issued aVtA J r! / a
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. Awaiting period of 48 hours after death
is required for all cremations.
D. CEMETERY OR CREMATORY
Method of Disposition:
BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ►
or Person -in- Charge )
CITY CLERK
Place of Disposition Sebastian Cemetery
Date of Disposition April 21, 1983
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.)
rid by CEMETERY Receipt No... , 34 6.......: 'Dated..... 4..-26 ..8 3 ..................
ist Price $ ..225:00 EACH Maximum No. Purial Spaces ..-r. .............
.EACH .
450.00
et Paid $ flat
permitted
R & R ISSUED (Data above this line for City Record only)
�:7r8 tl°t�•%
NO. 0525
Eleanor Hoffman
1206 W. Barefoot Circle
Sebastian,-Florida 32958