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Paid b General Receipt No. 172 February 19 1980
Y p Dated— ............................
last Price $100.00 each . Maximum No. Burial spaces ............
Discount $. -. fo ..lQtS Total area in square feet
................
Net Paid $400.00
• • • • • • • • • • • • .. Monument permittedfl a t ... .
R &R a toh (Data above this line for City Record only)
Name ��( C A/4 f
Unit Block
Lot
Date of Mark -out
Date of Burial. Time
Name of Funeral Home / -/ A.f
.:
Authorized by d I '' e- M?�-'t.
WILLHOFF, Ri 'chafd #o.8r4Mary E
Corner Estes & Gibson Sts
P. O. Box 224
Roseland, FL 32957
Lots 1, 2, 3 and 4 BLCK 7
Uni t #2
STATE OF FLORIDA
or ARTMENT OF HEALTH & REHABILITAO SERVICES ���'
VITAL STATISTICS
APPLICATION FOR BURIAL - TRANSIT PERMIT 4/ a
A.
(Type or Print)
1.
Name of First
Middle
Last
DATE Month Day Year
Deceased
OF
RICHARD
LAWRENCE
WILLHOFF DEATH AUGUST 31, 1987
2.
Place of Death City, Town or Location
Name of
(If neither, give street address)
County
Hosp. or
INDIAN RIVER ROSELAND
Inst.
HUMANA HOSPITAL — SEBASTIAN
3.
Name of Medical
® Physician
Address
Certifier NASIR RIZWI, M.D.
❑ Medical Examiner
13885
U.S. # 1 SEBASTIAN, FLORIDA
4.
Funeral Home/ Name
Address
r STRUNK FUNERAL HOME
1623 NORTH CENTRAL AVENUE SEBASTIAN, FLORIDA 32958
5. Check
Appro-
priate
Box
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b ® LILLIAN was contacted on 9/1/87 . He /she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
DR. RIZWI will complete and sign the medical certification of
cause of death.
c ❑ was contacted on . He /she verified that
, Medical Examiner, will complete and sign the
medical certification.
6. Funeral Director/ Sign ure Fla. Lic. No. /Reg. No. Date Signed
Direct Disposer 9/!1/87
B.
BURIAL - TRANSIT PERMIT
Permit No12281 -87 -327
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
withAe Local Registrar of the County in which death occurred.
Registrar or
Sub - Registrar S
�C
Date
Issued SEPTEMBER 1, 1987
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. Awaiting period of 48 hoiurs after death
is required for all cremations.
D. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition
® BURIAL []STORAGE Date of Disposition
❑ CREMATION ❑ OTHER (Specify)
Signature Sexton ) y�s
or Person-in-Charge e 1
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.)