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Paid by CEMETERY Reaipt No. . , 3 5 0. . . , , . , . . . Dat� . . 7 � 2 0 � 8 3 . . . . .
............. N�� 052i3
I.istPrices,300:00. ($150.00 Each) � -2- Deed �i528
. . . . Maximum No. Pucial S oes . . . . . . . . . . . . . . . . .
NetPaids 300.00 Flat Receipt N350
.. ... ... .. ... . . . . . Monument permitted . .. .. . .. .. . .. ... ... . .. . Chang ( Teresa ) Cushman
P.O.Box 282, Roseland,Fla.
Lots 31 & 32,B1k.39,Unit 1 Add.
(Dats abote t6L Lne for Ctty R�ecord only)
STATE OF FLORIDA
�ARTMENT OF HEALTH & REHABILITAT SERVICES
VITAL STATISTICS �
APPLICATION FOR BURIAL—TRANSIT PERNiIT
� 3i� ��a /� 3�
�� ��
A. {Type or Print)
1. Name of First Middle Last DATE Mo�th Day Year
Decessed OF
Robert Thomas Cushman Sr. DEATH July 15, 1983
2. Place of Death
Cou nty
Dade
City, Town or Location
Miami Beach, Florida
Name of (If neither, give street address)
Hosp. or
Inst. Mt. Sinai Medical Center
3. Name of Medical � Physician Address
Certifier Dr. Philip Samet M.D. ���;cal Examiner4300 Alton Road Miami Beach, FL 32140
4. Funeral Home/ Name Address
-fl;,�ctflts�,oser Pottinger & Son Fuheral Home Inc.,1200 S. Indian River Drive Sebastian, FL 32958
5. Check a�. The medical certification fias been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b� was contacted on . He/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
6. Funeral Director/
Direct Disposer
B.
will complete and sign the medical certification of
cause of death.
c� was contacted on . He/she verif�ed that
,/� _ � , , Medical Examiner, will complete and sign .the
��� �J�s-'/�, ��'.� �'
re�— Fla. Lic. No./Reg. No.
BURIAL—TRANSIT PERMIT
��
Permit No. �
Permission is hereby granted to dispose of this body.
❑ 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 Registrar of the County in which death occyrred.
Registrar or f..����� Date , � � � -�
Sub-Registrar Signature / � lssued
C. AUTHORIZATION for CREMA710N, DtSSECTION or BURIAL—AT—SEA
Signature , Medical Examiner Date
or
Medical Examiner, , gave authorization by telephone to
Funeral DirectorJDirect 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
Method of Disposition:
� BURIAL � STORAGE
� CREMATION � OTHER (Specify►
Signature of Sexton ►
or Person-in-Charge �
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition July 20, 1983
`"t` �
This permit must be endorsed by the Sext�i 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.)