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Name --aff E
Unit / n
Block /
Lot
Date of Mark -out
Date of Burial 6 1 G --
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Time ;a , '1
Name of Funeral- "Home_ rZ ,
Authorized by
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Paid by p 186 Donald L. Cole
General Receipt Not . , • , • • Dated April • ,30 C..1 • • • • • .
Cor Gibson & Berry Sts
List Price $.400.00 ........ Maximum No, Burial spaces P- 0. Box 62
Discount ;.....r.........
••• Total area in square feet _ _
...4...... • • Roseland, i^2 32957
Net Paid $ 400... Monument permitted .. fj4t: • • • • . B1k 48 Lots 2,3,4 &
Unit 2
(Data above this line for City Record only)
QState of Florida, Department of Health and Rehabilitative Services, Vital Statistics
APPLICATI *OR BURIAL — TRANSIT PERMIT
A. (Type or Print) a c;2�
1. Name of First Middle Last DATE Month Day Year
Deceased ISi el by. 1" 1 ✓ DEATH 12/ 21 195
2. Place of Death
City, Town or Location Name of (If neither, give street address)
County
Hosp. or
rd i an River
Roseland Inst. 2995 32nd Court
3. Name of Medical
Medical Examiner Address Phone Number
Certifier
7744 Bay Street
Noor Merchant,
M.O.
;< Physician Sebastian Florida 32968 (407)589::0879
4. Name of Funeral Home/
Address
Fla. Lic. No. /Reg. No.
Phone Number (Area Code)
Direct Disposer
4 623 North Central Avenue
t,jnk Punerali
!domes
P.A.
Sebastian F1 32958
1228
(407)562-2325
5. Check
a ❑
The medical certification has been completed and signed. A completed certificate of death accompanies
Appro-
this application.
priate z
Box
b ]
4hP= a was contacted on ; ; /`)r �/Sr -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 Noor Merchant M O will complete
and sign the medical certification of cause of death.
c ❑
was contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certification.
6. Place of se-bast ar: Cemetery In tate cemetery Removal
Final Disposition: matory - county: i nd i an River from state Donation
7. Funeral Director/ ignatu F.E. No. /Reg. No. Date Signed
Shoot Wieheeer
B BURIAL — TRANSIT PERMIT Permit No. 1228 -95 -0559
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 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.
Regia4na--or M � Date t Z `at IqS Duee Certificate
Subregistrar Signature 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. A waiting period of 48 hours after
death is required for all cremations.
D. CEMETERY OR CREMATORY
Methods of Disposition: Place of Disposition �,sf�7� ;�✓ �G�rtr��.E'y '
BURIAL ❑ STORAGE Date of Disposition i4
❑ CREMATION ❑ 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 HRS County Public Health Unit in the County where disposition occurred.
HRS Form 326, Feb 89 (Replaces Oct 87 edition which may be used)
(Stock Number: 5740- 000 - 0326 -2)