HomeMy WebLinkAbout1-18-23 Name H ■=i'r
Unit
Block t,
Lot
Date of Mark-out L `1 L
Date of Burial '7/ Z
Time (0 3r,-: .
Name of Funeral Home 1/1'7'
" i4
Authorized by
I
.• I
CA I
l
�� 9 �� I
- --4 1
0
z
t ,
o
Y U' •
V itf •. 1
No
tib
if
r r' v
aw . '*�
il
■
p i
tifj
VN d J v C !
Z. ip , e9'17
cs-
v
-•
CPn .....,7
rn I
;I p1 C
t � °�
IP.
•
•Y r H
I
`t V.
. * c
It k
. 1 o
i � ?
V I.
:)J
\c
7 1. Li.
`` I
i IJ
Li c
CJ‘ NJ k 1 a _.._._.
.....j .
�I
4, rte •
FIRS' State of Florida, Department of Health and Rehabilitative Services, Vital Statistics / 7;) (7C-A.(77-7
APPLICATI OR BURIAL — TRANSIT PERMIT •
A. (Type or Print) • a / C' 76 .
1. Name of First Middle Last DATE Month Day Year
Deceased I sham Roy James DEATH 03/03/92
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Sebastian Inst. 10520 US# 1
3. Name of Medical J Medical Examiner Address Phone Number
Certifier 937 Barefoot Blvd.
Muhammad Siddiaui, M.d. 7 Physician Barefoot Ba , Florida 329 8 (407)664-4349
4. Name of Funeral Home/ Address Fla. Lic. No./Reg.No. Phone Number(Area Code)
Direct Disposer
1623 North Central Avenue
Strunk Funeral Homes, P.A. Sebastian, Fl 32958 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 b Q Loic was contacted on 03/03/92 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 Muhammad Si rid i rtn i , M_rl_ will complete
and sign the medical certification of cause of death.
1 c ❑ was contacted on .He/she verified that
,Medical Examiner, will complete and sign the
medical certification.
6. Place of Sebastian Ce tery In stet:. %-metery/ Removal
Final Disposition: c •a; .ry ;name/county: Indian River n from state n Donation
7. Funeral Director/ ` Si. ature F.E. No./Reg.No. Date Signed
Direct Disposer / .
„,/B BURIAL — TRANSIT PERMIT
1228-92-0112
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 file. with the Local Registrar of the County in which death occurred.
❑ No extension of time for fi 0• the de.th certificat reque d.
Registrar or !� �� / Date - L� ._ 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
Methods of Disposition: Place of Disposition Sebastian C e m e t e r y
® BURIAL ❑ STORAGE Date of Disposition March 7 , 1 9 9 2
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ) 7
or Person-in-Charge) �,-c� . �--A�L Cwt -
/ 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.
HRS Form 326.Feb 89(Replaces Oct 87 edition which may be used)
(Stock Number:5740-000-0326-2)