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Unit �
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Lot �1�
Date of Mark-out /� �� �' �°� �y • ' '
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Date of Burial ��.�2 '�. • �$ � ,Time '� � �
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Authorized by ��' �'^��?�r _
�l�ck }�0 Lot llt
��o�d� Fcina Ruth
by BObby HiErs
Drnwdy Ws�y
3eba$tian� Fla.
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List Price $. .��-?.l........ , ,,'�/� "D �� �lkaximum No. Burial epaces . . .�. .. . ... �. , ��9 �a
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n;e�ount � � . .�?`!'. �' � ! 9 � / . . . �. . . . . . . I
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(Data above 1'hia llne for ty RRCOrd only) `�Z� �- �
STATE OF FLORIDA
�PARTMENT OF HEALTH & REHABIL�T� SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
��� �yd Ua
A. (Type or Print)
t. Name of Fi�st Middle Last DATE Month Oay Year
Deceased EDNA RUTH HIERS DEATH DECEMBER 19, 1985
2. P�ace of Death City, Town or Location
Countv jNDIAN RIVER SEBASTIAN
3. Name of Medic�
Certifier
4. F ?�����,i9���'
Di i
5. Check
Appro-
priate
Box
6. Funeral Director/
$'re�T�TSpe�,raC
B.
C
�
Name of �tf neither, give street address)
HosP. or HUMANA HOSPITAL - SEBASTIAN
Inst.
�Physician ess
�% �,(� ❑ edical Examiner o,%„3l�6 � � _� ,�/4 r���/�
STRUNK FUNE��eHOMES 916-17th STREET , YEROrBEACH, FLORIDA
a� The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b� Dfi. E. �. VANN, M.D. wascontactedon12/ZO/85 He/3heverifiedthat
this deat HEas from natural causes, that there was no accident nor other external cause of' death, and that
will complete and sign the medicaP certification of
cause of death.
c� � was contacted on . He/She verified that
, Medical Examiner, will comple3e and sign the
medical certification.
gnature
�_�
Fla. Lic. No./Rega+le.
BURIAL—TRANSIT PERMIT
!� 7.Z
[�ate Signed
DECEMBER 20, 1985
Permit No.1228-85-423
Permission is hereby granted to dispose of this hody.
� A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
grante : If it cannot be filed within this time limit, a"Funeral Director/Direct Disposer Report" will be filed
with e Local egist of the County in which death occurred.
Registrar or / i' Date DECEMBER 20, 1985
Sub-Registrar Signature Issued
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SE/�►
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.
Method of Disposition:
� BURIAL � STORAGE
� CREMATION � OTHER (Si
Signature of 9txtoTi ►
or Person-irnCFj,arge ►
CEMETERY OR CREMATORY �
� Place of Disposition ��F��s���� =� ' _
� Date of Disposition �� �,� �� —
.
This permit must be endorsed by the S�e� or person-in-charge (or by the Funeral Director/Direct Disposer when
and returned within 10 days to the local County Health Department in the County where disposition a:curred.
HRS Form 326, APR. 81
•(replaces previous editions which may be used.)
is no Sexton►