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Home My WebLink About2-30-16o,..r Ak W S-4;F, Ar i ✓ 11 N,v Ar Name N i Unit Block Lot 4 6 Date of Mark -out g A Q �� Date of Burial A 0 Time Name of Funeral Home !.. R Authorized by ..P ., JOHNS, Lonnie L. (Interred) JOHNS, Mrs. Lonzie L. (Essie) Te l 15m e>r-e, �L 3acjgr UNfT 2, Block 30, Lots 15, 16 0 • L-di J6 — � I ZZ�q� 3 y A. 1. /_ 16 © State of Florida lortment of Health and Rehabilitative Serv*Vital Statistics 6136 APPLICATION FOR BURIAL — TRANSIT PERMIT 1/9 (Type or Print) Name of First Middle Month I Day Year Deceased ESSIE MAE JOHNS D ATH FEBRUARYr 18, 1990 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or INDIAN RIVER FELLSMERE Inst. 88 N. PINE STREET r 3. Name of Medical Medical Examiner Address Phone Number Certifier CHARLES RATTRAY, M.D. Physician 2208 -8TH ST. VERO BEACH, FL 567 -4336 4. Name of Funeral Home/ Address I Fla. Lic. No. /Reg. No. Phone Number (Area Code) Direct Disposer 1623 N. CENTRAL AVE. STRUNK FUNERAL HOME, SEBASTIAN SEBASTIAN, FLORIDA 39285 441228 407 -589 -1000 5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate Box b ff8 DR. RATTRAY was contacted on 2 / 18 / 90 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 HE 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 6. Place of In state cemetery/ Removal Final Disposition: matory - name /c from state Donation 7. Funeral Director/ l re F.E. No. /Reg. No. Date Signed #1672 2/19/90 B. BURIAL — TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1226-90-089 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 ftlirA the death certificate requested. Registrar or OY - Date Date Certificate Subregistrar Signature - -' �-� L a _ Issued: 2/19/90 Due: C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA Q 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 -ol 48 hours after death is required for all cremations. Methods of Disposition: IDURIAL ❑ CREMATION Signature of Sexton ) or Person-in-Charge) CEMETERY OR CREMATORY Place of Disposition SEBASTIAN CEMETERY ❑ STORAGE Date of Disposition FEBRUARY 22, 1990 ❑ OTHER (Specify) 9.4 This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer when 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) is no Sexton)