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Name cg L� E ,L • Urn (3.1
Unit —
Block
Lot
Date of Mark -out I r
Date of Burial iLv Time I ° { � • 1`
State of Florida, Department of Health and Rehabilitative Services, Vital Statistics
APPLICA FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Claude Leon Combs OF
DEATH 01/14/92
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Palm Beach Lantana Inst. Ridae Terrace Health Care Center
3. Name of Medical Medical Examiner Address Phone Number
Certifier
Douglas Kwon M.D. g 6447 Lake Worth Road Physician Lake Worth.
4. Name of Funeral Home/ Address Fla. Lic. No. /Reg. No. Phone Number (Area Code)
Direct Disposer
1623 North Central Avenue
Strunk Funeral Homes P.A. Sebastian
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b
was contacted on ni /i A /nn within 72
hours after death. He /she verified that this death was from natural causes, that there was no accident
nor other external cause of death, and that nn,igl as Kwan. M R 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. Place of Sebastian Cemetery In state cemetery/ Removal
Final Disposilion: g crematory - na /count Indian River from state Donation
7. Funeral Director/ Signatu F.E. No. /Reg. No. Date Signed
B. BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -92 -0022
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a "Funeral Director /Direct
Disposer Report" will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for f death certificate req ted.
Registrar or �' Date / � Date Certificate
Subregistrar Signature Issued: !� Due:
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
Methods of Disposition: Place of Disposition.
Q BURIAL ❑ STORAGE Date of Disposition 6 i
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ) �
or Person -in- Charge)
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 HRS County Public Health Unit in the County where disposition occurred.
HRS Form 326, Feb 89 (Replaces Oct 87 edition which may be used)
(Stock Number: 5740 - 000 - 0326 -2)