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FLORIDA DEPARTMENT OF
HEALT
of Florida, Department of Health, Vital': tistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First
Middle
Last
Date Month Day Year
Deceased
Mildred
C.
Wilson
of
Death Dec. 26 2000
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Indian River
Vero Beach
Hosp. or
Inst. Indian River Memorial Hospital
3. Name of Medical
Address
14110 U.S.
#1
Phone Number
Certifier Syed Zaidi, M.D.
Sebastian,
FL
561- 589 -3755
Medical Examiner
Physician
4. Name of Funeral Home/13koc .^°:, a"I
Address
1623 N.
Central Ave.
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
Sebastian,
FL
1228
561- 589 -1000
Strunk Funeral Home
5. Check a. U The medical cerDrlcation nas oeen compieteu anu signeu. n wnjFnokou wM11wM VI V-1 a,,...,,,,a.... � ••••�
Appropriate application.
Box
b. �] Doreen was contacted on 12/27/00
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Zaidi 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
m Ical rtifi tion of paujo0obf death within 72 hours.
6. Funeral Director/ S' ature F.E. No. /Reg. No. Date Signed
Direct Disposer / 1862 12/27/00
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -00 -0599
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.
R Date Date Certifi e
Subregistrar Signature C ..Ca + M • ` � Issued: I `a V ` o•o Due: 1 64L.,
C.
Approval Number:
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
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
Method of Disposition: Place of Disposition Sebastian Cemetery
BURIAL
CREMATION
Signature of Sexton
or Person -in- Charge
STORAGE
OTHER (Specify)
Date of Disposition 1 AL � 3`"�" 2,=
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.
DH 326, 8/97 (Obsoletes all previous editions)
(Stock Number: 6740. 000-0326.2)
Distribution: While: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar