HomeMy WebLinkAbout2-46-014f
C) 0)
Unit
61ock
i38te�
NOIC
Authc
a
s'
Paid by =e eipt No.-.. 2I5........... Dated.... DEC..4, 1980........
List Price.. *: *.3 �D..OA. * *. Maximum No. Burial spaces .... .. .
Discount $ .................. TotaI area in square feet ................
* *350.00 ** Monument permitted Flat
Net Paid $....... perm ... .............
ak h (Data above this line for (Sty Record only)
GDeed ># 4.23
Mrs. Charles G Holmes
Box 268 Fleming Grant R,
X PCQ-
Block 46, lots.', Unjtd
At dh
Charles interred 12 -3 -8
State of Florida, Depa . ant of Health and Rehabilitative Services, V,` I ftatistics /1? %6
APPLIC:Rt'ION FOR BURIAL — TRANSIT PERMIT
� aZI
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Jule Elizabeth Holmes OF
DEATH 10/27/94
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Roseland lnst12975 Roseland Road
3. Name of Medical Medical Examiner Address Phone Number
Certifier
7744 Bay Street
N. Noor Merchant, M.D. Physician Sebastian Florida 32958 (407)589-0879
4. Name of Funeral Home / Address Fla. Lic. No. /Reg. No. Phone Number (Area Code)
Direct Disposer 1623 North Central Avenue
Strunk Funeral Homes P.A. ISebastian, F1 32958 1228 1(4071562-2325
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b X❑ Pam was contacted on !W1744 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 thatN. Noor Merchant, M.D. will complete
and sign the medical certification of cause of death.
C 11 and
contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certification.
6. Place o6ebast ian Cemeter y In Cemetery/ Removal
Final Disposition: � em torVjhar a /county: diart River F-1 from state I-1 Donation
�• Funeral Director/ Sig at F.E.
� — Reg -We- -� Date Signed
D
,No./
G7It 1 A /^ 17 /^A
B. BURIAL — TRANSIT PERMIT Permit N01228 -94 -0506
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 thR death certificate requested.
Registrar or /j Date Date Certificate
Subregistrar Signature Issued: Due:
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 -4 T° Ds
(o BURIAL ❑ STORAGE Date of Disposition QCA> -,— .?9, IIfT -V J11
❑ 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.
FIRS Form 326, Feb 89 (Replaces Oct 87 edition which may be used)
(Stock Number. 5740- 000 - 0326 -2)