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A. (Type ur ['lint)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
GLADYS McINTOSH DEATH April 15, 1984
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. Indian River Memorial HOspital
STATE OF FLORIDA
DEPARTMENT OF HEALTH & REHABILITOE SERVICES
VITAL. STATISTICS
APPLICATION FOR BURIAL — TRANSIT PERMIT
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3. Name of Medical )01 Physician Address
Certifier Alastair Kennedy, M.D. ❑Medical Examiner 777 37th Street., Vero Beach,
4. Funeral Home/ Name Address
Direct Disposer Strunk Funeral Home., 734 North Central Avenue., Sebastian, Florida
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b Eddie (Sec r y) was contacted on 14/17 He /she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
Dr. Kennedy
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. Funeral Director/
Direct Disposer
Signatut /
Fla. Lic. No. /Reg. No. Date Signed
4714- 7z
April 17, 1984
B. BURIAL — TRANSIT PERMIT
Permit No 128-84151
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 Coun y in which death occurred.
Registrar or
Sub- Registrar Signature
Date
Issued
April 17, 1984
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 (Specify)
Signature of Sexton 1 Dekbrah C. Krages, S t, Clerk
or Person -in- Charge ,)
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Place of Disposition Sebastian Cemetery
Date of Disposition 4/18/84
This permit must be endorsed by the Sexton or person -in- charge (u 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.)
RLOIK 17 LOTS 4 & 5
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GLADYS INTERRED:
& Gladys
McIntosh,
6
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Total area
Monument permitted
(Data above this line for City Record only)
Attach cy