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Paid by General Receipt No. . 17? Datd Februa
e ............. 19, 1980
Last Price ;100.00 each
Maximum No. Burial spaces ....
Discount $. -, ,�p.ux .IAtS
Net Paid
$400.00 Total area in square feet ................
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Name Z �l=
Unit
Block
onument permitted-Lau
(Data above this line for City Record only)
Lot
Date of Mark -out
4 r' °T Time
Date of Burial
Name of Funeral Home
Authorized by ''
I ,
WILLHOFF, Richard #o841yary E.
Corner Estes & Gibson Sts
P. O. Box 224
Roseland, FL 32957
Lots 1, 2, 3 and 4 BLCK 7
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FLORIDA DEPARTMENT OF
HEALT
A. (TYPE)
State of Florida, Department of Health, Vital Statistics < '�
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First
Middle Last
Date
Month Day Year
Deceased
of
Mary
Elizabeth Willhoff
Death
Aug. 14 2002
2. Place of Death City, Town or Location
Name of (If neither, give street address)
County
Hosp. or
Indian River Roseland
Inst. Sebastian River Medical Center
3. Name of Medical
Address
Phone Number
Certifier Adil Sanaulla, M D.
13885 U.S. #1
Medical Examiner Physician
Sebastian, FL
772 -5 9 -6844
4. Name of Funeral Home /Diwet- 9icpracal -.
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
1623 N. Central Avenue
Strunk Funeral Home
Sebastian, FL
1228
772-589-1000
5. Check a. The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. Lillian was contacted on 8/14/02
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Sanaulla will complete and sigh 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
medical ce fica o caus d th within 72 hours.
6. Funeral Director/ gn F.E. No. /Reg. No. Date Signied
_� ��, 1862 811402
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -02 0344
A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the I hysician 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.
E] No extension of time for filing the death certificate has been requested.
Reont- 01 or —+ Date Date Certificate
Subregistrar Signature %fit.. Issued: 8/14/02 Due: 8/11/02
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 CREMATORY
thod of Disposition: Place of Disposition Sebastian Cemetery
BURIAL STORAGE Date of Disposition El X26 .�
CREMATION
Signature of Sexton 1
or Person -in- Charge J}
OTHER (Specify)
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