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STATE OF FLORIDA
•PARTMENT OF HEALTH & REHABILIT
VITAL STATISTICS
SERVICES
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Narne of
Deceased
First
Arthur
747 ✓3/7 //
Middle Last DATE Month Day Year
OF
Albert Dom DEATH July 2, 1984
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Wabasso Inst. 9895 U.S. # 1
3. Narne of Medical
Certifier Peter Zabinsky, M.D.
] Physician Address
❑ Medical Examiner 245 N.W. Palm Bay Rd. Palm Bay, Fla. 32901
4. Funeral Home/ Name Address
EncarovOispticatxPottinger & Son Funral Home 1200 S. Indian River Dr. Sebastian Florida 32958
5. Check a E3 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro-
priate
Box
e
b
this application.
was contacted on He /she verified that
this death was 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.
c f1 was contacted on He /she verified that
i , Medical Examiner, will complete and sign the
'11
edical certiti .ion.
• i
6. F eral Director/
D rect Disposer
ature
`2368 July 2, 1984
Fla. Lic. No. /Reg. No. Date Signed
B.
BURIAL— TRANSIT PERMIT
Permit No 759 -556
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 County in which death occurred.
Registrar or
Sub - Registrar Signature
Date
Issued
eZ__
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:
B BURIAL ❑ STORAGE
CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge )
Place of Disposition
Date Qf Disposition
Sebastian Cemetery
July 6, 1984
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.)
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