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State of Florida, Departr' —t of Health and Rehabilitative Services, Vitaltistics . +✓ ��
A. ® APPLICAli iON FOR BURIAL — TRANSIT PERMIT
(Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Melvin Earl Yates D OTH 05/11/97
2. Place of Death City, Town or Location Name of (if neither, give street address)
County Hosp. or
Palm Beach Boca Raton Inst. Boca Community Hospital
3. Name of Medical
Certifier
Jonathan Kaplan, M.D
4. Name of Funeral Home/
Direct Disposer
Strunk Funeral Homes
5. Check
Appro-
priate
Box
a ❑
Medical Examiner
X I Physician
Address
Address
Phone Number
4800 Linton Blvd., S -107
Delray Beach, Florida 33445 (561)498 -4223
Fla. Lic. No. /Reg. No.1 Phone Number (Area Code)
1623 North Central Avenue
P.A. Sebastian, F1 32958 1228 (407)562 -2325
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b ® Melanie was contacted on n9;11 q/q7 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 that _Jonathan Kaplan, 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 Sebast i an Cemetery Id state cemete Vecounty: Removal
Final Disposition: rematory - Indian River from state Donation
7. Funeral Director/ ature F.E. No. /Reg. No. Date Signed
Btit- DtSpos�r f �e�,
B BURIAL — TRANSIT PERMIT . 1228 -97 -0232
Permission is hereby granted to dispose of this body.
Permit No.
❑ 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.
-jsi,�..u,e ray � ���� Date Date Certi cate
Subregistrar Signature f� C'— !""7't —'i Issued: Sh/ 97 Due: /G 4
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 Disposition 5;, g` 46%^4r1 n� Jat31t•�i�
BURIAL ❑ STORAGE Date of Disposition
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person -in- Charge)
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.
FIRS Form 326. Feb 89 (Replaces Oct 87 edition which may be used)
(Stock Number: 5740- 000 - 0326 -2)