HomeMy WebLinkAbout1-29-24RX Date /Time 11123/2011 12 :09 P1001
Nov 23 2011 12:21PM HP LASERJET FAX p.1
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Date of Burial
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Name of Funeral Home
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Clara Yates Finch
March 5, 1923 - November 23, 2011
Mrs. Clara Yates Finch, 88, died November 23, 2011 at Hendry
Regional Medical Center, Clewiston.
She was born in Douglas, Georgia and lived in Clewiston for 5 years
coming from Melbourne, Florida. Former resident of Fellsmere, FL.
Survivors include her son, Milton Yates of Clewiston; daughters, Alice
Yates Pickron of Clewiston, Judy Hiers of Grant /Valkaria; brother,
Marcus Stephens of Haines City; sister, Dattie Johnson of Dade City;
numerous 1/2 brother and sisters in Georgia; 10 grandchildren, 8 great -
grandchildren and 6 great - great - Grandchildren. She was preceded in
death by her husband, Minor Golden Yates; grandson, Little Jimmy
Pickron.
State of Florida, Department of Health, Vital Statistics
IHEALT T A PPLICATION FOR BURIAL - TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased Clara Yates Finch of November 23, 2011
Death
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hendry Clewiston Hosp. or Hendry Regional Medical Center
Inst.
3. Name of Medical Hans Charles M.D. Hdd Address Phone Number
Certifier 524 West Sagamore Avenue Clewiston, Florida 33440 (863) 983 -9121
Medical Examiner
4. Name of Funeral Home /Direct Disposal Fla. Lic. No. /Reg. No. Phone No. (Area Code)
Establishment Strunk Funeral Home orth Central Avenue Seba stian, F041870 (772) 589 -1000
and Crematory 32958
5. Check a. ❑ The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box /�, j
b. x}'24 Q was contacted on �� I
He /she verified that this de TIV as 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 within 72 hours.
C. ❑ was contacted on He /she verified that
, Medical Examiner, will complete and sign the
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -11 -541
_-E'A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within
72 hours.
❑No extension of time for f • e death certificate has been requested.
Registrar or Date Date Certificate
Subregistrar Signature t�V L� _� Issued: 11/23/2011 Due: 11/28/2011
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Approval Number: 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.
D. CEMETERY OR CREMATO �n
Method of Disposition: Place of Disposition r_— x ��b an 120 ,Q me Vj� BURIAL ❑STORAGE Date of Disposition &tit � t
❑CREMATION ❑OTHER (Specify)
Signature of Sexton
or Person -in- Charge (J. <---)�7 .
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 County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
DH 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740- 000 - 0326 -2) Pink: Local Registrar
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL CEMETERY
HOME of ftucm KIND
For information contact:
Kip Kelso - Cemetery Sexton
Sebastian Municipal Cemetery
(772) 589 -2545
City Clerk's Office
City Hall, 1225 Main Street
Sebastian, FL 32958
Office (772) 388 -8215 or 388 -8294
Fax: (772) 589 -5570
FUNERAL HOME: SIRtINK MINERAL HOME & CREMATORY
ADDRESS: 1623 No. Central Ave.
S; BA&„AN,TL32958
PHONE #: (772) 589.1000
(C a One) II
OPEN BURIAL LOT Lot � 1 Block 2� Unit I
OPEN CREMAINS LOT Lot Block Unit
OPEN COLUMBARIUM NICHE �Niche Block ��,,Un�it�
BURIAL DATE AND SERVICE TIME :.3J�1 I l 2-IJ �ZI It (1� l I d
FOR DECEASED: Llavo— b T�K�h
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
( st provide pro er documentation of owne hip)
Name /Signature Date
I certify that I have determined the ownership of the above described site, that all site fees and
administrative fees have been paid and authorize opening of same.
7 E AND SIG ATURE OF LICENSED FUNERAL DIRECT
p-no �— 1� c
Name Signature Date
Cemetery Sexton Certification:
I certify that I have checked the ownership information by viewing the owner's deed and confirming
with Clerk's office and that all fees have been paid:
C6melfiry S to Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.