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Unit
Block
Lot
Date of Mark-out « �
Date of Burial /� � � �� Time �� •� � � �' ' /�
_ __ _ _ . __
_ __ _ _ --_- -__ . .
Name of Funeral Home � 1.�Q L/ /� /�_;�
Authorized by
• � .C'iK'_..-,.rF„r.`�
� � � Daed ;r 44�
J !
,_:. �
Ck. ;�575� q/9�?p ,,'
Paid by General Receipt No . ............. .... Dated.........................;:,yR.:% "' �+shb��flE�s ,�. �.
, �OX t �U1S12F?a ,��t°.
Iast Price $....�*.��'�e�R�;*' � Se�astian �1a. 3295R
• Maximum No. Burial spaces ............ �
DSscount $..........-....... Total area in aqnare faet ................
Net Paid $....�':x:��.�,..Q��'�' Monument • ��a� L��S r 2 3 - t31k. 36
permitted ` '
..................... Unit 1
(Data above this line for City Record only) � r
�,,....; t; ;' ';, .; , } ,
�
�..._.......,. _ ..,..,.-._.-.—�-- -.y...
� STATE OF FLORI� �` �`"
� DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES ,� 36
VITAL STATISTICS
W YAHTMI:NT UF MI:ALTH AND /' /
""""""."^T""''�""'°`-' APPLICATION FOR BURIAL—TRANSIT PERMIT u
A.
1. Name of
Deceased
or Print)
First
EDNA
�, riace ot Ueath
County
INDIAN RIVER
3. Name of Medical
Certifier JOSEPH A. H
Middle
ALICE
City, Town or Location
VERO BEACH
Last
ASHBURNER
DATE Month Day Year
OF
DEATH JANUARY 6, 1989
Name of (If neither, give street address)
Hosp. or
Inst. INDIAN RIVER MEMORIAL HOSPITAL
�hysician Address 567-7111 Phone Numbe
.D. ❑ Medical Examiner 2300 — STH AVE. VERO BEACH, FLA.
4. runeral Home/ Name Address Phone Number (Area Code
X.�C�K4�� STRUNK FUNERAL HOME 1623 N. CENTRAL AVE SEBASTIAN FLA 4
5. Check
Appro-
priate
Box
6. Funeral Director/
X�;Dliii��lORs���r
•� , 07-589-1000
a� The medical �ertification has been completed and signed. A completed certificate of death accompani
this application.
b(� _ JO NN . was contacted on 1/6/89 within 7
hours after death. He/she verified that this death was from natural causes, that there was no accident n
other external cause of death, and that - DR JOSFPN NT7 T M n will complet
and sign the medical certification of cause of death.
c �
medical certification.
_ was contacted on , He/she verified tha�
, Medical Examiner, will complete and sign th
Signatur . Fla. Lic. No./Reg. No. Date Signed
4�1672 1/6/89
B• BURIAL—TRANSIT PERMIT 1228-89-0
Permission is hereby granted to dispose of this body.
Permit No.
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue h�
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a"Funeral Director
Disposer ReporY' will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filing t deaih certificate requested
Registrar or Date Dat2 Certificate
Subregistrar Signature �• Issued: 1/6/89 Due:
C.
�
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
Signature , 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.
Method of Disposition:
� BURIAL ❑ STORAGE
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Persen-ifl.Ga�cgo_ 1 f,l � q•
CEMETERY OR CREMATORY
Place of Disposition SEBASTIAN CEMETERY
Date of Disposition � J y'�
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton�l
and returned within 10 days to the local County Health Department in the County where disposition occurred.
HRS Form 326, Oct 87 (Replaces May 86edition which may be used)
(Stock Number: 5740-000-0326-2)