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STRUNK`FUNERAL HOMES, P.A. 5650 '
CASH ADVANCE ACCOUNT- SEBASTIAN
916 17TH ST. ,
VERO BEACH, fl- 32960 63- 1205/670
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FLORIDA DEPARTMENT OF
HEALT State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
William L. Wade, Sr. Death May 8 2006
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. Indian River Memorial Hospital
3. Name of Medical Address Phone Number
Certifier Richard Cunnin ham, D. M. 901 37th Street
Medical Examiner Physician Vero Beach, FL 772 - 987 -5600
4. Name of Funeral Ho sa Address Fla. Lic. No. /Reg. No. Phone No. (Area Code)
Establishment 1623 N. Central Ave.
Strunk Funeral Home Sebastian, FL 1228 772- 589 -1000
5. Check a. E] The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. Dr. Cunninghamwas contacted on 518106
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 within 72 hours.
C. was contacted on He /she verified that
Medical Examiner, will complete and sign the
'MeVol certocWof cause of death within 72 hours:
6. Funeral Director/ F.E. No. /Reg. No. Date Signed
1862 518/06
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit Nol 228-06 -0189
❑ A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has,
been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within
72 hours.
No extension of time for filing the death certificate has been requested.
Date Date Certificate
Subregistrar Signature 1 Issued: 518106 Dye: 5/13/06
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL- AT-SEA
Approval Number: 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.
D. CEMETERY OR CREMATORY
M thod of Disposition: Place of Disposition Sebastian Cemetery
BURIAL 0STORAGE Date of Disposition
OTHER (Specify)
Signature of Sexton
or Person -in- Charge }� ,
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.
Distribution: White: Cemetery or Crematory
DH 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number. 5740- 000. 0326 -2) Pink: Local Registrar 47.10