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STATE OF FLORIDA JJ �
PARTMENT OF HEALTH & REHABILITR f SERVICES h 7 �9 6 7
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VITAL STATISTICS
APPLICATION FOR BURIAL— TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
DEATH
JOHN JOSEPH WEAVER Jan 28, 1982
2. Place.of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Sebastian Inst. Sebastian River Med. Ctr.
3. Name of Medical )] Physician ~"""C"
Certifier Kip Kelso M.D. ❑Medical Examiner P.O. Box 28, Sebastian, F1.
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 Mar i P SrhaPgQPr CPr'y was contacted on WS . 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- Ke I 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/ /� Signatur Fla. Lic. No. /Keg. No. LJdlC 01911CU
Direct Disposer n -11A I I !I 1 � Al
B.
RIAL— TRANSIT PERMIT
Permit No,
1228 -018
Permission is hereby granted to dispose of this body.
)ETXA 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 Si
Date
Issued
C.� AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature
or
, Medical Examiner 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:
X❑ BURIAL ❑ STORAGE
[]CREMATION ❑ OTHER (Specify)
Signature of Sexton
or Person -in- Charge
Place of Disposition Re ha S+' an Ceme a *y
Date of Disposition F "'' ' "' 7 7 982
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.
FIRS Form 326, APR. 81
(replaces previous editions which may be used.)