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FLORIDA DEPARTMENT OF
HEALT
(TYPE)
Name of
Deceased
First
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
Middle Last
Joseph W
2. Place of Death City, Town or Location
County
i ndian River
3. Name of Medicai
Certifier MiC�e18 SCOtt,
nMedical Examiner �
4. Name of Funeral Home/Direct Disposa
Establishment
Roseland
.D.
Kolmel
Name of
Hosp. or
Inst.
Date
of
Death
(If neither, give street address)
8095 12
1�60 36th Street
Vero Beach. FL
Address
1623 N Central Ave
/- �7-�a
Month Day Year
June 9 2004
one Number
772-562-7777
Fla. Lic. No./Reg. No. Phone No. (Area Code)
Strunk Funeral Home ( Sebastian _ FL � I � 22$ I 772-589-1000
5. Check a. � The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b� Mellssa was contacted on 6/9/04
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. SCOtt will complete and sign the medical
certification of cause of death within 72 hours.
6. Funeral Director/
,�y��
a.
c
�
c. � was contacted on
certific 'o - ause of death within 72 hours.
Si F.E. No.lReg. No.
1862
BURIAL - TRANSIT PERMIT
He/she verified that
, Medical Examiner, wili complete and sign the
Date Signed
6/9/04
Permission is hereby granted to dispose of this body. Permit No. 1228-0�-0232
� 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 funerai director and will not be able to complete the medical certification of cause-of-death section ot the death certificate within
72 hours.
�No extension of time for filing the death certificate has been requested.
RegTSh�aror-'• Date Date Certificate
Subregistrarsignature �,,�,BJ„[/M.,� ���.�-a.�-� Issued: 6/9/04 Due: 6/14/04
Approval Number:
AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
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 alt cremations.
Method of Disposition:
�/ BURIAL
�CREMATION
Signature of Sexton j
or Person-in-Charge �
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
�STORAGE Date of Disposition � �� S�p lj/
�OTHER (Specify)
0
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.
Distribution: White: Cemetery or Crematory
DH 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number 5740-000-0326-2) Pink: Local Registrar
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. • DEED #448
THE SEBASTIAN CEMETERY
City of Sebastian
Sebastian, Florida
RECEIPT IS HEREBY ACKNOWLEDGED OF TNE SUM OF:
Three hundred and no/00************************** Dollars ($300.00********)
FROM: Joseph Ko.ZmeZ
• : . . ��]
Sebastian, Florida 32958
on this 22 day of May , 1981 for the purchase of the following
described Cemetery Lot(s) upon the terms and conditions as stated herein:
Description of Property:
� Cemetery Lot(s)# 28.29,30 B1ock# 3� Unit# 1 Addition
Purchas� Price: Three hundred and no/oo***** mllars($ 300.00*�*).
Terms and'conditions of sale:
Paid by cash in fu11.
This contract sha11 be binding upon both parties, the seller and the purchaser, when
approved by the owner of the property above described.
I, or we, agree to purchase the above described property on the terms and conditions
stated in the foregoing instrument:
The City of Sebastian agrees to se11 the above mentioned property to the above named
purchaser(s) on the terms and conditions stated in the above instrument.
�
City of ebastian
--�-��%-C.�
Witness