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Name
Autho
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tNANl Z
HERNANDEZ
UNIT 2, Block 35, Lots 1, 2
Mari e S. 4err"ex - 'i o��r w(
QState of Florida, Depart of Health and Rehabilitative Services, Vita tistics /Z 3
API Al FOR BURIAL — TRANSIT PERMIT /✓
ua
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Marie Suit Hernandez DEATH February 20, 1993
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Brevard Melbourne Inst. Holmes Regional Nursing Center
3. Name of Medical Medical Examiner Address Phone Number
Certifier 407 - 724 -4545
John H. Potomski, Jr. DO Physician 720 E. New Haven Avenue, Melbourne, FL 32901
4. Name of Funeral Home / Address Fla. Lic. No. /Reg. No. Phone Number (Area Code)
Direct Disposer 1010 E. Palmetto Avenue
Brownlie & Maxwell Funeral Home Melbourne, FL 32901 0000049 407 - 723 -2345
5. Check
Appro-
priate
Box
a ja
this application.
has been completed and signed. A completed certificate of death accompanies
b ❑ 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.
6• Place of Sebastian Ce tery In state cemetery/ Removal
Final Disposition:Sebastia FL/ AX I crematory - name /county: Indian River from state Donation
7. Funeral Director/ Signature F.E. No. /Re . No. Date Signed
Direct Disposer 596 2/23/96
B.
BURIAL — TRANSIT PERMIT
Permit No. 493075
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 nor im/Regi he ertificate cannot be filed within this extended time limit, a "Funeral Director /Direct
Disposer Report" will be filed with t the my in which death occurred.
@(No extension of time for filing ert
Registrar or Date 2/23/93 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
Sebastian Cemetery
S
Methods of Disposition: Place of Disposition eb FL
astina I
7IKI BURIAL
❑ CREMATION
❑ STORAGE
❑ OTHER (Specify)
'ate of Disposition 2 �:? ' -�
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)