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Paid by CEMETERY Receipt No... 415.......... Dated ..... 7 /31'85 ................ NO.
f iat Price $...A00.-.00 ........ Maximum No. Rudai Spaces.....? :......... 1056
Net Paid $ . , 3 .....00........ Monument permitted .....Flat............. Jo n H H.
& Bessie C. Shivers
Lots 17 & 18, Block 41, Unit 1 Addition � Concha Dr.
Sebastian, Florida 32958
(Dab above thb Une for Qty Record only)
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STATE OF FLORIDA
SPARTMENTOF HEALTH & REHABILITIOE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL— TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
JOHN H SHIVERS DEATH SEPT 30 1985
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
INDIAN RIVER SEBASTIAN Inst. HUMANA HOSPITAL SEBASTIAN
3. Name of Medical ❑ Physician Address
Certifier GEORGE MITCHELL, D.O. ❑ Medical Examiner 7925 BAY STREET SEBASTIAN FLORIDA
4. Funeral Home/ Name Address
Direct Disposer STRUNK FUNERAL HOME 734 N CENTRAL AVENUE SEBASTIAN FLORIDA
6. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b SHELLY was contacted on .10/1./85 . He /she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
DR- MITCHELL 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.
10 -1 -85
..Funeral Director/ ature Fla. Lic. No. /RegrNe: -s Date Signed
8 BURIAL— TRANSIT PERMIT Permit No. 1228 -85 -319
Permission is hereby granted to dispose of this body.
0(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
with the Local Re istrar of the County in which death occurred.
Registrar or Date 10 -1 -85
Sub - Registrar Signature DndAtlt Issued
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA
?• ��Bigrfetu7e , 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
Method of Disposition: Place of Disposition Se- bQS71A,J C'eme r<z-
LfPURIAL ❑ STORAGE Date of Disposition la 3- YS
q CREMATION [-] OTHER (Specify)
Signature of Sexton
or Person -in- Charge
Deborah C. Krages, Citya-71erk
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.)