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State of Florida, Departn --k of Health and Rehabilitative Services, Vital a' tistics
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APPLICAI ioN FOR BURIAL — TRANSIT PERMIT
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A. (Type or Print)
1. Name of First
Middle Last DATE Month Day Year
Deceased
Eugene
Ewell Yates DEATH 01/04/95
2. Place of Death
City, Town or Location Name of (If neither, give street address)
County
Hosp. or
Brevard Little Hollywood In %70 Lawrence Avenue
3. Name of Medical
Medical Examiner Address Phone Number
Certifier
200 E. Sheridan Ave.
Mark E. Reese M.D.
N
Physician Melbourne, Florida 32901 407)725 -4500
4. Name of Funeral Home/
Address
Fla. Lic. No. /Reg. No.
Phone Number (Area Code)
Direct Disposer
623 North Central Avenue
lebastian,F1
Strunk Funeral Homes.
P.A.
32958
1 1228
407)562-2325
5. Check a ❑
The medical certification has been completed and signed. A completed certificate of death accompanies
Appro-
this application.
priate
Box I:X
$;_3& was contacted on g} ()5,19 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 th*dark F,- Reese, 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.
mace Febastian Cemetery
• t-uneral ulrector/
B. BURIAL — TRANSIT PERMIT 228 -95 -0008
Permission is hereby granted to dispose of this body.
Permit Nd.
❑ 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 he death certificate requested.
Registrar or Date / �� Date Certificate
Subregistrar Signature Issued: ! Due:
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 -t—
Methods of Disposition: Place of Disposition 1"1 -t;,.,
X BURIAL ❑ STORAGE Date of Disposition 1 <. / 5 9�\
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge) , s C -L,, A
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)