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STATE OF FLORIDA 3 a
APARTMENT OF HEALTH & REHABILITIO& SERVICES
5. Check a The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ❑ was contacted on . He /she verified that
Box 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
C m "cal e
• 1770 October 21 1986
6. Funeral Director/ V Signature r Fla. Lic. No. /Reg. No. Date Signed
6�inelx
B. BURIAL— TRANSIT PERMIT'S,..
Permit No./--�
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. If it cannot be filed within this time limit, a "Funeral Director /Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or Date
Sub - Registrar Signature !�u�!t` ®'"""�'`-'' Issued T
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature
or
, Medical Examiner Date
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. i
D. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cemetery
XIBURIAL ❑ STORAGE Date of Disposition October 24, 1986
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton)
or Person -in- Charge ) _
This permit must be endorsed by the Sexton or person- in- chargeuor by tU 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.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
VITAL STATISTICS
APPLICATION FOR BURIAL - TRANSIT PERMIT
A.
(Type or Print)
"
I.
Name of
First Middle Last
DATE Month Day Year
Deceased
Gladys Clara Duty
OF
DEATH October 21, 1986
i.,_ ... 2.
Place of Death
City, Town or Location Name of
(If neither, give street address)
County
Hosp. or
Indian River
Vero Be&Qh Inst.
Vero Beach Care Center
3.
Name of Medical
E3CPhysician
Address
Certifier Muhammad
Farooq, M.D. ❑ Medical Examiner
777 37th St. Vero Beach Fla.
4.
Funeral Home/
Name
Address
[ww&KXhW=Pottinger & Son Funeral Home 1200 S. Indian River Dr. Seba%ti.an Fla,
5. Check a The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ❑ was contacted on . He /she verified that
Box 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
C m "cal e
• 1770 October 21 1986
6. Funeral Director/ V Signature r Fla. Lic. No. /Reg. No. Date Signed
6�inelx
B. BURIAL— TRANSIT PERMIT'S,..
Permit No./--�
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. If it cannot be filed within this time limit, a "Funeral Director /Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or Date
Sub - Registrar Signature !�u�!t` ®'"""�'`-'' Issued T
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature
or
, Medical Examiner Date
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. i
D. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cemetery
XIBURIAL ❑ STORAGE Date of Disposition October 24, 1986
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton)
or Person -in- Charge ) _
This permit must be endorsed by the Sexton or person- in- chargeuor by tU 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.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)