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BURIAL — TRANSIT PERMIT 1228 -91 -0171
Permission is hereby granted to dispose of this body. Permit No.
❑ 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 filipq the death certificate reque d.
Registrar or Date / Date Certificate
Subregistrar Signature Issued: �/ Due:
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: Place of Disposition
BURIAL ❑ STORAGE
Date of Disposition
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge) it vC� • �� ��
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.
Ii Form 326. Feb 89 (Replaces Oct 87 edition which may be used)
-ck Number: 5740- 000 - 0326 -2)
State of Florida, De, nent of Health and Rehabilitative Services, at Statistics
APPLICATION FOR BURIAL — TRANSIT PERMIT
4. (Type or Print)
1. Name of First
Deceased Ralph
Middle Last DATE MQrtth2 Year
Adams W
/ay
OF
DEATH
?. Place of Death
City, Town or Location Name of (If neither, give street address)
County
Brevard
Hospp. or
Melbourne Inst.Holmes Regional Medical Center
3. Name of Medical
Certifier
Medical Examiner Address Phone Number
1601 S. Apollo Blvd.
Physician Melbourne, Florida 32901 (407)768-2816
I. Name of Funeral Home/
Direct Disposer
Address
Fla. Lic. No. /Reg. No.
Phone Number (Area Code)
1623 North Central Avenue
Strunk Funeral Homes,
P.A.
Sebastian, F1 32958
1228
(407)562 -2325
�. Check a ❑
The medical certification has been completed and signed. A completed certificate of death accompanies
Aupro-
this application.
priate
Box b a❑
Jamie 04/03/91
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 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.
Place of Sebastian Cemetery
state cemetery/ Removal
Final Disposition:
c tory - na e/c nty: Indian River from state Donation
Funeral Director/
turn F.E. No. /Reg -No- Date Signed
Direst t3ispasisi"
i 672 04/03/91
BURIAL — TRANSIT PERMIT 1228 -91 -0171
Permission is hereby granted to dispose of this body. Permit No.
❑ 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 filipq the death certificate reque d.
Registrar or Date / Date Certificate
Subregistrar Signature Issued: �/ Due:
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: Place of Disposition
BURIAL ❑ STORAGE
Date of Disposition
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge) it vC� • �� ��
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.
Ii Form 326. Feb 89 (Replaces Oct 87 edition which may be used)
-ck Number: 5740- 000 - 0326 -2)