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9.2Z.84 NO.
. Dated . .
PaidbyCEMETERYReceiptNo.,00���-�������� .............._.2_•••••••••
List Price S ,300 : 00 .. .. ..... Ma�cimum No. EuTial Spaces . .... ...... .. ... . � � � �
..f1at ,
300 . 00 Monument permitted . .. • • • • • • • • • •' Ca therine E . Savag�
Net Paid S . . . . . . . . . . . . . . . . .
. Unit 1 additional 343 S.W. Columbus S•
Lots 17 & 18, Block 38, Sebastian, Florida 32958
(Data �bove Nbb Une !or CItY Iiernrd only) _
_------
STATE OF FLORIDA
,�EPARTMENT OF HEALTH & RENABILIT. dE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERNIIT
,� , �' � � � . � ��
A. (Type or Prini)
1. Name of First Middle Last DATE Month Day Ye.
Deceased O F
�EQR�E AI Mc1�J SA�E DEATI-�ent� 2�� 1984
2. Ptace of Death City, Town or Loc�ion Name of (If neither, give street address)
County Hosp. or
I nd i an R i ver Sebas t i an Inst. ��3 S.IJ. Co 1 umbus St _
3. Name of Medical �] Physician Address
Certifierptichaela Tovatt-Scott ❑MedicalExaminer 2300 5th Avenue.�Vero eeach
4. Funeral Home/ Name Address
Direct Disposer Strunk Funeral Home. . 734 North Central Avenue. . Ydilt�X8�4�flElf Sebast ian
5. Check a[� The medical certificatinn has been completed and signed. A completed certificate of death accompa
Appro- this application.
priate b ��. Ga e (nurse
Box � Y � was contacted on �L. He/she verified
this death was from natural causes, that there was no accident nor other external cause of death, and
D�. Tovatt–Scqtt will complete and sign the medical certificatio
cause of death. " `
6. Funeral Director/
Direct Disposer
B.
C
�
�
was contacted on . He/she verified
, Medical Examiner, will complete and sign
medical certification.
ature
Fla. l.ic. No./Reg. No.
BURIAL—TRANSIT PERMIT
Date Signed
Sept. 21, 1984
Permit No.
1228-E4-:
Permission is hereby granted to dispose of this 4ody.
�( A five day extension of time for filing the death certificate (exclusive of weekends) has been requested
Registrar or
Sub-Registrar Sign
Signature
or.
Alledical Examiner,
granted. If it cannot be filed within thi time limit, a"Fun�ral pirector/Direct Disposer Report" will be
wi h the Local Registrar of the County n which death occurred.
�Date Sept. 21 , 1984
`�--� Issued
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
, Medical Exainirier Date
, gave authorization by telenhone 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 d
is required for all cremations.
Method of Disposition:
� BURIAL � STORAGE
� CREMATION � OTHER (Specify)
Signature of Sexton )
or Person-in-Charge �
CEMETERY OR CREMATORY
r
Elizabeth A�id, Deputy City Clerk
Place of Disposition Sebastian Cemetery
Date of Disposition September 24 , 1984
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Se�
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.)