HomeMy WebLinkAbout1-35-17MI�LLER, Mrs. Josephine C�
(mother of Jorn J. Fitzgerald)
t?NIT l, Block 3�� Lo� 17
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(Data ebove this line for City Record only)
�
_
A. (Type or Print)
1. Name of First
Deceased
STATE OF FLORIDA
`EPARTMENT OF HEALTH & REHABILIT° 'VE SERVICES �-- / � � � 5 L"��
_ V17AL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERNIIT
Middle
Last
JOSEPHINE; C. MILLER
DATE
OF
DEATH
Month Day Year
,1 une 13 , 1984
2. Place of Death City, Town or Location Name of Ilf neither, give street address)
County Hosp. or
Indian River Sebastian inst. Humana Hospital-Sebastian
3. Name of Medical Physician Address
Certifier Farhat J. Khawaja, M.D. []Medical Examiner 7754 Bay St., Sebastian, Florida
4. Funeral Home/ Name Address
DirectDisposer Strunk Funeral Home., 734 North Central Avenue., Sebastian, Florida
5. Check a� The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b� Mar sec' was contacted on
Box Y� �� �1�3.. He/she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
Dr. Khawa ja witl complete and sign the medical certification of
cause of death.
6. Funeral Director/
Direct Disposer
�
C
�
�
medical certification.
was contacted on . He/she verified that
., Medical Examiner, will complete and sign the
Fla. Lic. No./Reg. No.
�� I
BURIAL—TRANSIT PERMIT
Date Signed
J
1228-84-199
Permit No.
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. If it cannot be filed w�thin this time limit, a"Funeral Director/Direct Disposer Report" will be filed
with the Local Registrar of the �ounty in which death occurred.
Registrar or
Sub-Registrar Signatu
Signature
or
�
Date ,June 14, 1984
Issued
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
, Medical Examiner Date
Medical Examiner, , gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examirier'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)
Siynature of Sexton ►
or Person-in-Charge )
CEMETERY OR CREMATORY
Place of Disposition
Date of Disposition.
This permit must be endorsed by the Sexton or person-in-charye (ar by the Funeral Directur/Direct Disposer when there is no Sexton;
and returned within 10 days to the local County Health Department in the County where disF�osition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)