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BLOCK 7, Lot 5, UNIT #2
Marguerite C. Fisher
Gibson Street
P. O. Box 67
Roseland, FL 32957
DEED #382
Name !' "-z Ci X
Unit
Block 7
Lot �% p
Date of Mark-out :% ci L
Date of Burial Time r
Name of Funeral Home
Authorized by --
r' a
a
DEED #3
U FISHER, Margueri to C.
Paid by General Receipt No ....170.... .... Dated..Februart,� 19, 1980... Gibson Street
P. O. Box 67
List Price $1.00.00......... Maximum No. Burial spaces ........I... Roseland, FL 32957
Discount $.... ............ Total area in square feet ................
Net Paid $U10-00 ......... Monument permitted ... flat • • • • . • • • . • • • BLK 7 LOT 5 UNIT #2
R &R atch (Data above Ws line for City Record only)
ff D A DEPARTMENT OF EALTH
A (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
a -7 -��
1. Name of First
Middle Last
Date Month Day Year
Deceased
of
Marguerite
Civilla Fisher
Death Sept. 11 2004
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 Ralph Geiger, M.
13838 U.S.
41
Medical Examiner Physician
Sebastian,
FL
772 —S81 -6900
4. Name of Funeral Home /Direet-DI51MI
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
1623 N. Central
Ave.
Strunk Funeral Home
Sebastian, FL
1228
772 - 5891000
5. Check a. U The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. Lisa was contacted on 9/13/04
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that -Dr. Geiger will complete and sign 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
njedi9dl'Artifj4tioT6f cause of death within 72 hours.
6. Funeral Director/ Si atu F.E. No. /Reg. No. Date Signed
Dirieet -etse r Z 1862 9/111/04
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -04 -0354
A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician 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.
No extension of time for filing the death certificate has been requested.
r or 0 Date Date Certificate
Subregistrar Signature ,a„p��,e t/Y1 Issued: 9/11/04 Due: 9/16/04
'T
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
Method of Disposition: Place of Disposition Sebastian Cemetery
BURIAL STORAGE Date of Disposition 7 jj" A
CREMATION OTHER (Specify)
Signature of Sexton
or Person -in- Charge /� Q , I
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, 6/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number 5740- 000 -0326.2) Pink: Local Registrar