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HomeMy WebLinkAbout1-32-27Name ilnit Block Lot Date of Mark -out �� Date of Burial Ea ? Time Name of Funeral Home- --I+ I 1 0 - � 4 t /[ P - 3. Name of Medical Medical Examiner Address (407) 725 -5300 Phone Number Certifier Thomas G. Hoffman M.D. 1 Physician 1317 Oak Street, Melbourne, Florida 32901 4. Name of Funeral Home/ Address Fla. Lic. No. /Reg. No. Phone Number (Area Code) Direct Disposer 1950 29th Street Cox - Gifford Funeral Home Wero 562 -2365 5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate Box b ki Thomass— Hr)ffman M_n- was contacteeonuary 3' 1991 ithin 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 Rn will complete and sign the medical certification of cause of death. c ❑ was contacted on . He /she verified that , Medical Examiner, will complete and sign the medical certification. 6. Place of In state cemetery/ Sebastian Cemetery Removal Final Disposition: U crematory - name /county: from state Donation 7. Funeral Director/ Signature F.E. No. /Reg. No. Date Signed Direct Disposer --I .�� B. BURIAL — TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No1421 -044 -1 c3c31 ❑ 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 c7 Date February 3, 1991 Date Certificate Subregistrar Signature - Issued: Due2t=hr„ary 13, 1 AA1 C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA Signature or 14 , Medical Examiner Date 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. D. CEMETERY OR CREMATORY Methods of Disposition: ❑ BURIAL ❑ CREMATION Signature of Sexton ) or Person-in-Charge) ❑ STORAGE ❑ OTHER (Specify) Place of Disposition Date of Disposition 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. HRS Form 326, Feb 89 (Replaces Oct 87 edition which may be used) (Stock Number: 5740- 000 - 0326 -2) c - .� State of Florida, P�'-jrtment of Health and Rehabilitative Servic htal Statistics AP►- L.ICATION FOR BURIAL — TRANSIT PERMIT 0 � ` A. (Type or Print) 1. Name of First Middle Last DATE Month Day Year Deceased OF Caroline V. Keifner DEAT4"ebruary 3, 1991 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Indian River Vero Beach Inst. 12906 129th Street 3. Name of Medical Medical Examiner Address (407) 725 -5300 Phone Number Certifier Thomas G. Hoffman M.D. 1 Physician 1317 Oak Street, Melbourne, Florida 32901 4. Name of Funeral Home/ Address Fla. Lic. No. /Reg. No. Phone Number (Area Code) Direct Disposer 1950 29th Street Cox - Gifford Funeral Home Wero 562 -2365 5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate Box b ki Thomass— Hr)ffman M_n- was contacteeonuary 3' 1991 ithin 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 Rn will complete and sign the medical certification of cause of death. c ❑ was contacted on . He /she verified that , Medical Examiner, will complete and sign the medical certification. 6. Place of In state cemetery/ Sebastian Cemetery Removal Final Disposition: U crematory - name /county: from state Donation 7. Funeral Director/ Signature F.E. No. /Reg. No. Date Signed Direct Disposer --I .�� B. BURIAL — TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No1421 -044 -1 c3c31 ❑ 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 c7 Date February 3, 1991 Date Certificate Subregistrar Signature - Issued: Due2t=hr„ary 13, 1 AA1 C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL —AT —SEA Signature or 14 , Medical Examiner Date 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. D. CEMETERY OR CREMATORY Methods of Disposition: ❑ BURIAL ❑ CREMATION Signature of Sexton ) or Person-in-Charge) ❑ STORAGE ❑ OTHER (Specify) Place of Disposition Date of Disposition 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. HRS Form 326, Feb 89 (Replaces Oct 87 edition which may be used) (Stock Number: 5740- 000 - 0326 -2) ..:7..:... PI 4A +4s Ayfwv,� W A d Uh qvy os —/*Y A : bir .s c -Te 67/ -it IAr tj lei or vita ;� 71 G t6 d