HomeMy WebLinkAbout2-20-04_ ^i_
ITEMS FOL. �� DEBITS ✓ �
l 6
• � 1; •
CREDITS
DR.
1 BALANCE
CR.
11 n
Name
Unit
Block
Lot
Date of Mark-out
Date of Burial
Name of Funeral Home
Authorized by
Time /0 ('c'c -4 /4'7
Paid by Genera t No.
o,6
List Price $
Discount $
Net Paid $
Dated
7//' A
Maximum No. Burial spaces
Total area in square feet
Monument permitted
i
D
7 (Data above this line for City Record only) ,/ ��3.
A.
1.
State of Florida, Depart t of Health and Rehabilitative Services, Vitgliatistics
APPLICN FOR BURIAL — TRANSIT PERMIT IF
(Type or Print)
Name of First
Deceased
Robert
Middle
Patrick
Last DATE Month Day Year
OF
Sharkey, Sr. DEATH 05/22/91
2. Place of Death
County
Saint Lucie
City, Town or Location
Fort Pierce
Name of (If neither, give street address)
Hosp. or
Inst. 7504 Citrus Park Boulevard
3. Name of Medical
Certifier
Asuncion M. Luyao
, M.D.
4. Name of Funeral Home/
Direct Disposer
Strunk Funeral Homes,
5. Check a ❑
Appro-
priate
Box b
c ❑
Medical Examiner Address Phone Number
1701 SE Hillmoor Drive
Physician Port St. Lucie, Florida 34952 (407)878 -4922
Address Fla. Lic. No. /Reg. No. Phone Number (Area Code)
916 17th Street
P.A. Vero Beach, Florida 32960 130 (407)562 -2325
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
Joan
was contacted on 5/22/91 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 Asuncion M. Luyao,M.D. will complete
and sign the medical certification of cause of death.
medical certification.
was contacted on He /she verified that
Medical Examiner, will complete and sign the
6. Place of Strbastian Cemetery � In state cemetery/
Final Disposition: Fix crematory - name /county:
7.
Funeral Director/
Aiicnneor
Signature
( Q 71?).r.H1
Indian River
F.E. No. /Reg. No.
Removal
n from state
n Donation
Date Signed
a533 05J�/91
B.
BURIAL — TRANSIT PERMIT
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 normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director /Direct
Disposer Report" will be filed wi the Local Registrar of the County in which death occurred.
❑ No extension of time for filing , - death certifica - requested.
Permit No 0130 -91 -0257
„RegSubr� `
egistrar Signatu
Issued: .
Date
/ �%
Date Certificates '9 /Q/
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.
Methods of Disposition:
IV BURIAL
❑ CREMATION
Signature of Sexton )
or Person -in- Charge )
❑ STORAGE
❑ OTHER (Specify)
CEMETERY OR CREMATORY
4° 9 '77
Place of Disposition
Date of Disposition
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)