HomeMy WebLinkAbout2-06-10State of F%W, Department of Health, Vital Statistics
T APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print) 10 98 -00470
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Antonia Pappas DEATH October 27, 1998
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. Palm Garden Of Vero Beach
3. Name of Medical Medical Examiner Address Phone Number
Certifier 1485 37th Street
Richard Eisenmann, M.D. , Physician Vero Beach, Florida 32960
4. Name of Funeral Home / Address I Fla. Lic. No. /Reg. No.1 Phone Number (Area Code)
Direct Disposer 1950 20th Street
Cox - Gifford Funeral Home Vero Beach FL 32960
5. Check
Appro-
priate
Box
a-0 I
The medical certification has been completed and
this application.
1423 1 (407) 562 -2365
A completed certificate of death accompan
b ❑x was contacted on IQ -27 -g$ 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 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 In state cemetery/ Sebastian Uemetery Removal
Final Disposition: F7crematory - name /county: from state Donation
7. Funeral Director/ i n to F No./ Rea o. Date Signed
Direct Disposer
B BURIAL — TRANSIT PERMIT 1423 -98
Permit No.
Permission is hereby granted to dispose of this body.
❑ ./� five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
`bvould 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 Lo I Registrar of the Coun in which death occurred.
❑ No extension of time for filing the deat ertificate quested. % c
Registrar or C/ Date 10/27/98 Date Certificate
Subregistrar Signature l^ Issued: Due:
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
Signature
or
, Medical Examiner Date
Medical Examiner, , gave authorization by telephone to
Fi eral 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
Sebastian Cemetery
Methods of Disposition:
❑ ]BURIAL
❑ CREMATION
Signature of Sexton )
or Person-in-Charge)
❑ STORAGE
❑ OTHER (Specify)
Place of Disposition
Date of Disposition
This permit must be endorsed by the Secton 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.
DH 326. 10/96 (Replaces HRS Form 326 which may be used)
(Stock Number: 5740- 000 - 0326 -2)