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Name
Unit_
Block.
Lot
41
Date of Mark -out I ,�, 1 ':
Date of Burial I � 1 Time f Q,' C C IA I14
Name of Funeral Home cc y lak
Authorized
DEED N 513
Paid by CEMETERY Receipt No ... 323 .......... Dated ....... U28J$3 .............. John H Smith NA. 0513
List Price $ ......19.Q. 9A ... $l 5 0 . /Each Maximum No. Parisi Spaces..... ? .. &10r Anna W. Smith
300.00 Flat Rt. #1,Box 45, Sebastian,Fla.1
Net Paid $ .................. Monument permitted ....................... LOTS M 1 & 2, BLOCK 47, UNIT #2
PAID IN FULL /CKN178, $300.00
(Data above this Une for City Record only)
�1
A.
1. Name of
State of Florida, De ant of Health and Rehabilitative Services •I Statistics
APPLTION FOR BURIAL — TRANSIT PERMIT
or Printl
First Middle
Deceased Last DATE Month Day Year
John H. Smith DEATH
County December 25, 1990
2. Place of Death City, Town or Location Name of (If neither, give street address)
p. or
Indian River Sebastian Hos Hos 13225 U.S. #1
-X7
waniC 6 Medical
Certifier
Mohammad Idrees M.D.
4. Name of Funeral Home/
Direct Die --
Medical Examiner
Address
Phone Number
Street Center, Sebastian, FL. 589 -0069
p Fla. Lic. No No. Phone Number (Area Code)
1950 -20th Street
Cox - Gifford Funeral Home JVero Beach, Florida 32960 1 1423 (407) 562 -2365
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b [ Mohammad Idrees Dec. 26,1990
was contacted on within 72
hours after death. 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 ❑ was contacted on . He /she verified that
medical certification. Medical Examiner, will complete and sign the
6. Place of
Final Disposition: Sebastian
7. Funeral Director/
Direct Disposer
In state cemetery hh ian Cemetery
crematory - name kffff y
Removal
from state n Donation
No. Date Signed
December 26, 1990
B. BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. _442 _i _j_j"0
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director /Direct
Disposer Report" will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filing the death certificate requested.
Registrar or Date Date Cer 'ficat
Subregistrar Signature Issueg.ec. 26, 1990 Due: an.e3 1991
if
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. A waiting period of 48 hours after
death is required for all cremations.
CEMETERY OR CREMATORY
Methods of Disposition:
❑ BURIAL ❑STORAGE Place of Disposition
El CREMATION ❑OTHER (Specify) Date of Disposition
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 HRS County Public Health Unit in the County where disposition occurred.
'RS Form 326, Feb 89 (Replaces Oct 87 edition which may be used)
Stock Number: 5740- 000- 0326 -2)