HomeMy WebLinkAbout2-35-10;a 3S J � �
s
E
;a 3S J � �
<�
;a 3S J � �
DUNN$
IXTNNs
UNIT 21 Block 35, Lots 9, 1p
'� —
n
,�Q
ue�jl -;o-
1�t
V/
FLORIDA IMPART 03MM OP
I HEAL
State of FI a, Department of Health, Vital Statistics
APPLICAN FOR BURIAL — TRANSIT PERMIT 0
X 1//
133 -
A. (Type or Print) y
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Amy Dunn DEATH April 12 1998
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Brevard Micco Inst. 3840 Church Street
3. Name of Medical Medical Examiner Address Phone Number
Certifier
Farhat Khawa
M. D.
7754 Bay Street, Sebastian, Fl 561 - 589 -3000
4. Name of Funeral Home/ Address Fla. Lic. No. /Reg. No. Phone Number (Area Code)
Direct Disposer 1623 N. Central Ave.
Strunk Funeral Home Sebastian, FI 1228 561- 589 -1000
5. Check
Appro-
priate
Box
a ❑
The medical certification has been completed and signed. A .completed certificate of death accompanies
this application.
b/< Michelle was contacted on 4/13/98 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. Khawaia will complete
and sign the medical certification of cause of death.
c ❑
medical certification.
was contacted on . He /she verified that
, Medical Examiner, will complete and sign the
b• Place of Sebastian Cemete In state ceme y/ Removal
Final Disposition: crema ry ame /county: Indian River from state Donation
7. Funeral Director/ 7z_�f� F.E. No. /Reg. No. Date Signed
9i eet spemw 1862 4/13/98
B.
BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
Permit No. 1228 -98 -0178
❑ 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 certificate r nested.
ae9iat a+`-e Date Date Certific to
Subregistrar Signature Issued: 4 � 2 Q Due: �f *7 Q g
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature Medical Examiner Date
or
Medical Examiner, gave authorization by telephone to
Funeral Director /Direct Disooser. Date
The Medical Examiner's approval must be obtained before disposal by ar,,a 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 A41.z -
® BURIAL ❑ STORAGE Date of Disposition Aa,-,-e /r, /918
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge)
This permit must be endorsed by the Secton or person -in- charge (or by the Funeral Director /Direct Disposer when there is no Sexton)
and returned within 10 days to the local County Health Department in the County where disposition occurred.
DH 326. 10/96 (Replaces HRS Form 326 which may be used)
(Stock Number: 5740- 000 - 0326 -2)