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Block i
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Date of Mark -out
Date of Burial Time `4 - y>7 -
Paid by QbuaraL Receipt No. ?'!........ Dated...P
List Price $..- 0:,...... Maximum No. Burial spaces /s C3G --
Discount $.........,... Total area In square feet.....
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State of Florida, Departme f Health and Rehabilitative Services, Vital istics
APPLICAT1FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
I. Name of First Middle Last DATE Month Day Year
Deceased OF
ELLEN DURYEA KASER DEATH JANUARY 9 1996
2. Place of Death City, Town or Location Name of (If neither, give street address)
County
Hosp. or
HILLSBOROUGH PLANT CITY Inst. SOUTH FLORIDA BAPTIST HOSPTTAT.
3. Name of Medical
Certifier
STEVE WAYNE SMITH MD
Meolcal Examiner Address Phone Number
708 west Palmetto Street
Physician Plant City FL 33567 813 754 -3344
4. Name of Funeral Home/ Address Fla. Lic. No. /Reg. No. Phone Number (Area Code)
7303 BABCOCK STREET SE
FOUNTAINHEAD MEMORIAL PALM BAY FLORIDA 32909 1442 407 727 -3977
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
prlate
Box b
c ❑
Jewel of Dr. Steve W. Smith office was contacted on 1/10/96 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 Dr Smith will complete
and sign the medical certification of cause of death.
was contacted on . He /she verified that
Medical Examiner, will complete and sign the
medical certification.
6. Place of SEBASTIAN In state cemetery/
Removal
Final Disposition: CEMETERY FYI cremator ame ty: INDIAN RIVER from state Donation
7. Funeral Director/ Signat a 2> F.E. No. /Reg. No. Date Signed
�r FE2389 1/10/96
B. CSURIAL — TRANSIT PERMIT
Permission is hereby ermit No. FH0001442 -13 -96
y 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 certi 'cate requested.
Date Date Certificate
Subregistrar Signature Issued: 1/10/96 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.
ID. CEMETERY OR CREMATORY
Methods of Disposition: Place of Disposition A— .. ,
IQ- BURIAL ❑ STORAGE Date of Disposition
❑ 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)