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Paid by General Receipt No. .` -„�,�, ,�, '�' ��, �� _ �� G�� � u
� . . . . . . . . . Dated. .��,' • • • •1! `.� ,
List Price �. . . �Sd . � � ..... ..
Discount $. . . . -------.. . '-�aximum No. Burial spa¢es . . .� . . .
Net Pnid $. .l�'-� _ � � Total area ia sqnare !xt ���, , . . . . . .
..... P��'�''�Q�ume°L Permitted �.�� ,
�,� ................
_ �f �Data a6ove ti�is line !or Cib' Record �
— °�Y)
Name
Unit
Block_
Lot
�
Deed #ia6 ,�
Gregory & marguerite Dillon
�alores Street, Twin Lakes
Sebasti�, Fla. 39958
Lots lI & 1,2, of Black 36
...
Gl n � 'P" /
Date of Mark-out o�02� ��
.
Date of Burial ��,�9,�
Ti me ,` (",} (� �- �;
d r
Name of Funer8l Home_ r.;Iw
� ��F�
Authorized by ,:.. _ � ..,.,
. ; �',✓ . �' ,,��
QState of Florida, Depart t of Health and Rehabilitative Services, Vit atistics
APPLIC�N FOR BURIAL — TRANSIT PERMIT �
d-. ,�r�� /: �
�� �.3 ��
A (Type or Print) �'� -�
1. Name of First Middle Last DATE Month Day Year
Deceased Maro erite Marie Dillon �F 02/O1/199�
DEATH
2. Place of Death
County
3.
4.
Indian River
Name of Medical
Certifier
David DePutron,
Name of Funeral Home/
Direct Disposer
, Town or Location
�seland
Medical Examiner
Address
1623
Name of (If neither, give street address)
Hosp. or
Inst. Sebastian River Medical Center
Address Phone Number
1323� U.S. Hwy # 1
Sebastian Florida 32953 407 589-688
Fla. Lic. No./Reg. No. Phone Number (Area Code)
th Central Avenue
Strunk Funeral Homes, P A I Sebastian, F1 3Z95i3 I 1"l"lt� I ( 4U / 1 JbG-L.iLJ
5. Check a❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b� g�h,,,,a was contacted on n� ini i� oo�rithin 72
hours after death. He/she verified that this death was from natural causes, that there was no accident
nor other external cause of death, and that nav��l DePLtron� D.O. will complete
and sign the medical certification of cause of death.
�❑ was contacted on . He/she verified that
___ , Medical Examiner, will complete and sigr, the
medical certification.
6• P�ace of Sebast ian Cemete
Fnal Disposition:
7• Funeral Director/
O+cact-8ie�eee�
e.
In state
cremat�
Signaty
. /
county: Indian River
F.E. No.�'id�
BURIAL — TRANSIT PERMIT
Removal
from state n �onation
Date Signed
Permit No. 1228-95-0069
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 as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a"Funeral Director/Direct
Disposer Report" will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filin the death certificate requested.
Registrar or �� IDssued: - �� <-S Date Certificate
Subregistrar Signature � Due: � - � ' �s
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.
�
CEMETERY OR CREMATORY
Methods of Disposition: Place of Disposition
L� BURIAL ❑ STORAGE Date of Disposition 9 9—
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ) �
or Person-in-Charge )
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sextonl
and returned within 10 days to the local HRS County Public Health Unit in the County where disposition occurred.
HRS Form 326. Feb 89 1Replaces Oct d7 edition which may be used�
(Stock Number. 5740-000-G326-2)