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319 ,o-27-s2 No. 0 5 U 8
Paid by CEMETERY Roceipt No . . . . . . . . . . . . . . . . . Dated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
List Price S . . . .�17.`2 s 00 , , , , , , Maximum No. Euiiai Spaces . . . . : . 3 . .-. . . . . . . Mae F . Craig
Flat 8600 U.S. #1, Lot #72
Net Paid S ....675 : �� • • • • • • Monument permitted . .......... ..... ...... . Riverview Motor Home Villa
Sebastian, Fla.
R&ERDI�SUED (Data above tbfs line for City Record oo1Y) C��° �Ji �(o�� 7/ �'G`37, U/X�
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Name .
f , , `��
Unit
Block ,�' � _
Lot
;�'"r ..:�^ , . ,
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Date of Mark-out
� "; �. : °� .
a a � �;� .
� : , , Time ��
Date of Burial
,�,�^"' �, `
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Name of Funeral Home
Authorized by
FLURIDA DEPARTMENT OF
HEALT
A. (TYPE)
1. Name of
Deceased
2. Place of Death
C�unty
Brevard
State of Florida, Department of Wealth, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
First
Anna
City, Town or Location
Palm Bay
3. Name of Medical
Cert�er John Potomski, D.O.
Medical Examiner Physician
4. Name of Funeral Home/Dic�t.�icpcc�l Address
Establishment
Strunk Funeral Home
5. Check a
Appropriate
Box
Middle
L.
��.9 -�3 � -1-. ��
Last Date
of
Kel ler Death
of (If neither, give street address)
or
Month Day Year
J uly 7 2001
nst. integrated Heaith Services of Palm Bay
720 E. New Haven Avenue
Melbourne, FL
Phone Number
61-724-4545
1623 1�. Central Ave. Fla. Lic. No./Reg. No. Phone No. (Area Code)
Sebastian, FL 1228 561-589-1000
The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
b. � kathy was contacted on 7/ 9/ O1
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Potomski will complete and sign the medical
certification of cause of death within 72 hours.
c. � was contacted on He/she verified that
, Medical Examiner, wili complete and sign the
medical cert�cation of cause of death within 72 hours.
6. Funeral Director/ � Sig�urA e�fM�/ � F.E. No./Reg. No. Date Signed
�pes�'�' �//./�s� e. "L "> � 3 9 7 5 7/ 8/ 01
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. j 22$-01-0347
� A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours.
�No extension of time for filing the death certificate has been requested.
R�gi�Frer�o� Date Date Certificate
Subregistrar Signature Issued: Due:
c. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number: Date
Medical Examiner, , gave authorization by telephone to
Funeral DirectodDirect 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.
�. CEMETERY OR CREMATORY
Method of Disposition: Place of Disposition Sebastian Cemeterv
�BURIAL �STORAGE Date of Disposition f�(� `� �
—T
�CREMATION �OTHER (Specify)
Signature of Sexton
or Person-in-Charge ,,��,� �J. �� � .
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.
Distribulion: White: Cemetery a Crematory
DH 326, 8/97 (Obsoletes all previous edilions) Yellow: Funeral DireUOr or Dired Disposer
(Stock Number: 5740-000-0326-2) Pink Lacel Registrer
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