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HomeMy WebLinkAbout1-22-02NBC �yi4✓ � ,,. 4 4 .: ' 4 C9 _ �...___..._._.._:. _...._.._...- - .. 1p �. S4 N � •. t p 4 1 � l ty CO rJ r hid 1�A .m o N, ft Z UL v cw O TT— Z t. y,�� �" �• i � � � tt�T 3 �� �'-> d Icz a I r� ro I M rj 7Z a . -;. . �;f:�zS:y,artmicaiw ;fun4. ,:t.;;: .,rv...:..::.• ..,. ._ .. -u....,.__.._........�r..- ,D_e_aJ Of 31 State of Florida, Departme, Health and Rehabilitative Services, Vital S tics lql -,e;,2 _ Z_0& APPLICATION FOR BURIAL - TRANSIT PERMIT A. (Type or Print) 1. Name of First Middle Last DATE Month Day Year Deceased Joe Boyd OF 04/1611992 DEATH 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Hendry LaBelle Inst. 930 Highway 80,West 3. Name of Medical Medical Examiner Address Phone Number Certifier P. 0. Box 625 11. V. Guadiz,PI. D. Physician LaBelle, Florida 33935 4. Name of Funeral Home/ Address Fla. Lic. No. /Reg. Nr(407)562-232'j ne Number (Area Code) Direct Disposer 1623 North Central Avenue Strunk Funeral Homes, P.A. Sebastian, Fl 32958 1228 5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate Box b ® Nu rsp was contacted on ()I / 12 fl / 1 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 Ii. V. Guadiz,M. D. 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 Sebnst, ian Cemetery In state cemetery/ Removal Final Disposition: cre ory - na /c nty: Indian River from state Donation 7. Funeral Director/ eF.E. No. /Reg. No. Date Signed 4Brt'ett'Bt��jJi38 /Ve�t / Z41L 1672 04 / 2. (1 / 191)2. B BURIAL - TRANSIT PERMIT 1228 -92 -0196 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 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 �death tificate req sted. Registrar or , �- Date 7 / Date Certificate Subregistrar Signature Issued: �-�"_��* Due: Irl 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. D. CEMETERY OR CREMATORY Methods of Disposition: Place of Dispositione!!9` lr ;- -`ems 91 BURIAL ❑ STORAGE Date of Disposition Z- ❑ CREMATION ❑ OTHER (Specify) Signature of Sexton ) Z —n 1 or Person -in- Charge) � `� �L-�Z ' '' C:)-'r 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. TARS Form 326, Feb 89 (Replaces Oct 87 edition which may be used) (Stock Niunbec 5740 - 000 - 0326 -2)