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STATE OF FLORIDA L� "✓
OPARTMENT OF HEALTH & REHABILITOE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT "7
A.
(Type or Print)
1.
Name of First Middle
Last
DATE Month Day Year
Deceased
OF
MYRON
ELLISTT
POTTER, JR.
DEATHOCTOBER 11, 1986
2.
Place of Death
City, Town or Location
Name of
(If neither, give street address)
County
Hosp. or
BREVARD
MICCO
Inst. 9972 SEBASTIAN RIVER DRIVE
3.
Name of Medical
Physician
Address
Certifier MICHAEL
ZIMMER, M.D. Medical Examiner 2300 5TH
AVE. VERO BEACH, FLORIDA 32960
4. Funeral Home/ Name Address
Direct Disposer STRUNK FUNERAL HOME 734 N. CENTRAL AVENUE SEBASTIAN, FLORIDA 32958
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate DR. ZIMMEK 10 -13 -86
Box b j2 DR. 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
HE will complete and sign the medical certification of
cause of death.
c ❑
medical certification.
was contacted on . He /she verified that
., Medical Examiner, will complete and sign the
6. Funeral Director/ gnat Fla. Lic. No. /Reg. No. Date Signed
Ae 4Kl�}K
2088 OCTOBER 13, 1986
B. BURIAL— TRANSIT PERMIT Permit No. 1228 -86 -387
Permission is hereby granted to dispose of this body.
five day extension of tirne 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 OCTOBER 13, 1986 '
Sub- Registrar Signature _P Issued
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 1
or Person -in- Charge )
Place of Disposition
Date of Disposition.
This permit must be endorsed by the Sexton or person- in-charge (or by the Funeral Dire /Di
and returned within 10 days to the local County Health Department in the County where diloositi
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
fsposer when there is no Sexton)
urred.
Name o Al 0
Unit A 2? n
Block ! .
Lot
LOTS 9 & 10 UNIT # 2 Addn Block 49
Rules & Regulations issued:
Paid by CEMETERY Receipt No.... #31 . 6 ....... Dated . , , August . . 17 ..19 82....... NO, {� (�
0503
List Price $ . , .450 :00 . ..... Maximum No. Puna! Spaces .aR.—. , , Myron E. Potter,Sr.
450.00 ... and /or Lewis L. Potter
Net Paid $ ...... ............. Monument permitted ...................... 9972 Sebastian River Drive
R & R Iss ue d
Sebastian, Florida 32958 (Micco):
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(Data above this Une for City Record only) "tom p�IUJ �jv/ `IEG�cr -C