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Maximum No. Burial spaces
Total area in square feet
Monument permitted
(Data above this line for City Record only)
BLI ZNiAN
BLI EON
UNIT 2, .Bock 2.0, Lots 5, 6
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STATE OF FLORIDA ilk
�ARTMENT OF HEALTH & REHABILITA SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
AGNES BLIZMAN DEATH December 1, 1983
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. Vero Beach Care Center
3. Name of Medical ) Physician Address
Certifier M. Farooq, M.D. ❑ Medical Examiner 777 37th Street.,Vero Beach, Florida
4. Funeral Home/ Name Address
Direct Disposer Strunk Funeral Home., 734 N. Central Avenue., Sebastian, Florida
5. Check
Appro-
priate
Box
6. Funeral Director/
Direct Disposer
a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b XE] Linda (sec' y) was contacted on 12/1/83 He/she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
Dr. Farooq will complete and sign the medical certification of
cause of death.
c
medical certification.
z
ature
B.
was contacted on He /she verified that
, Medical Examiner, will complete and sign the
Fla. Lic. No. /Reg. No.
BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
)®A five day extension of time for iling the death certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed wit in this time limit, a "Funeral Director /Direct Disposer Report" will be filed
with the Local Registrar of the unty in which death occurred.
Date Signed
December 1, 1983
Permit No 1228-83 -306
Registrar or
Sub - Registrar Signatur
Date
Issued
December 1, 1983
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. CEMETERY OR CREMATORY
Method of Disposition:
BURIAL ❑ STORAGE
CREMATION ❑ OTHER
Signature of.6exton -4-
or Person -in- Charge )
Place of Disposition
Date of Disposition
.Sf 4 4 Joe— •
lam- y•83
ait4(ftV /ria?A-(//).
Deborah C. Krages, City Clerk
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.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)