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Paid by Genernl Receipt No. . ' '�L
•(••��. .. Dated.. '�-�-/—,�� m�'S•.J%��.' f�liller
List Yrice �..;�-5�, � • • ... N, Indian Rivez� Dr.
.. .... biaximum No, Burial spa�es p• 0. Q o x ? A 5e b.
Discount , • ..... ...
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Net Peid $. ,�/-5?J ` . . . . . . . 1 o t s 1 F , & 17 � .
..... Monument permitted ., blQCk�35� Sac. 2 ur
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(Data above. this line for City R,ecord only) �r :-�
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�lack 35 I,ots 16, � Unit. 1
F`itzgerald, John J. (Interred) Deed �198
Millery Mrs. Josephin.c C. (mother of J.J. ,ritzgerald)
pK�`� `7 ` �9'T-'tfiv`.-s"j" — � /.li/y..� F.. �Gx�'/'r'�'�'t.icc�tl' /�1�'%�
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Name -��;:t.i ���'�-CtQvni�
J
Unit !
Block ��
Lot _� _
Date of Mark-out "7,�,�8 �'�.��
Date of Burial �` � Time �2t'a�3 -�N -
Name of Funeral Hbme ._� +- �-` i4 `,:, "
Authorized by_,�
� State of Florida, Departm f Health and Rehabiiitative Services, Vital �tics
APPLICATla1G FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First
Deceased
John
2. Place of Death
County
inalan xive
3. Name of Medical
Certifier
t�arv �liverman.
4. Name of Funeral Home
Direct Disposer
Strunk Funeral
5. Check
Appro-
priate
Box
Middle
Joseph
City, Town or Location
E�l
L" � / "�+'' � � �
�� � S �
�r ,L
Last DATE Month Day Year
OF
Fitzoerald DEATH �%/�S/9�
Name of (If neither, give street address)
Hosp. or
I nst.
T�r� i �n D; �ro�- \,fon,...-, ., 1 LI.-..�,..; +.. 1
Medical Examiner Address Phone Number
.,�,D, Physician ��00 Jth. Avenue _
�"ero eac . �?U ( a � � �
/ Address Fla. Lic. No./Reg. No. Phone Number (Area Code)
16?� :�orth Central Avenue
Homes. P.A. Sebastian. F1 339s4 �� (''1S ?-����
a❑ The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b I� ��gT�,. was contacted on n-� ��o �n� within 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 ('.a r� S i 1 vPrman .�vt n will complete
and sign the medical certification of cause of death.
c ❑
6• Placeof Sebastian Cemet
Final Disposition:
�� Funeral Director/ �
Direct Disposer
medical certification.
Prv In state c
/
�/county:
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
F.E.
Removal
�eT n from state n Donation
No./F�e�-tdv-- Date Signed
/��� �_ ,_.. ..._
g. BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
Permit No. 1228-95-0366
❑ 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 filing the death certificate requested.
Registrar or Date Date Certificate
Subregistrar Signature Issued: Due:
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.
Methods of Disposition:
� BURIAL
❑ CREMATION
Signature of Sexton )
or Person-in-Charge ) _
❑ STORAGE
❑ OTHER (Specify)
CEMETERY OR CREMATORY
Place of Disposition s%'-�� ���-•�j � �t/ •
Date of Disposition 8�� / 9'�
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 HRS County Public Health Unit in the County where disposition occurred.
I HRS Form 326. Feb 89 (Replaces Oct 87 edition which may be used)
i (Stock Number: 5740-000-0326-2)
l
CEM
�dex :
Las t h�lame
Address 1
Address 2
c�+�
Deed �#
Unit �
Lot Number
Lot Numb�r
Lot IJumber
Lot hlumber
Comment
C�rr�me r-r�:
#
CitY of �ebasti�n, FL - C7meterY Lc���
MILLE� First �lame JOSEPHINE C.
N. IPlDIAN RIVER DR.
p,p. BOX 2
SEBASTIAN St�t<=-� � FL
198 Qate 03-21-73 A�•�ount
1- Block # 35 �
16 Interred FITZGERALD JOHN!(SON)
17 Interred Josephine �. Mi1�=r
Interred
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Dte Interred - -84
D'e Interred
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