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,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)