HomeMy WebLinkAbout1-12-02 . .
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�oxrn�AiD���wxTT`Exrof State of Florida, Department of Health,Vital Statistics
yy-`l "�-� - APPLIC•N FOR BURIAL — TRANSIT PERMIT • t ;P �
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A. (Type or Print) 1t t
1. Name of First Middle Last DATE 1 Month Day Year
Deceased OF
Alexander M. Sims DEATH Jan. 1 1998
2. Place of Death City,Town or Location Name of (If neither,give street address)
County Hosp. or
Brevard Melbourne Inst. Holmes Regional Nursing Center
3. Name of Medical _J Medical Examiner Address Phone Number
Certifier
John Potomski, D.O. Physician 720 E. New Haven Avenue, Melbourne, Fl 561-724-451
4. Name of Funeral Home/ Address Fla.Lic.No./Reg.No. Phone Number(Area Code)
Direct Disposer 1623 N. Central Ave.
Strunk Funeral Home Sebastian, Fl 1228 561-589-1000
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b Kathy was contacted on 1 /2/98 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 Dr. Potomski 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 Sebastian Cemetery In state ceme-ry Removal
Final Disposition: E' At atory- ate, county: Indian River El from state n Donation
7. Funeral Director/ Fro natur: r F.E.N. :-g.No. Date Signed
Direct Disposer 1862 1 /2/98
B. BURIAL — TRANSIT PERMIT 1228-98-0002
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.
Re9 ref- Date / Date Cert c e
Subregistrar Signature � � /---k Issued: /' ` 9 Due: / 7 J
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 154S7-;gxv c7,n ere ey
5 BURIAL ❑ STORAGE Date of Disposition 9a4 &R� Cv/ /9 58
❑ CREMATION ❑ OTHER(Specify)
Signature of Sexton )
or Person-in-Charge) .../....:. -. - 77/.._-�
This permit must be endorsed by the Secton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton)
and returned within 10 days to the local County Health Department in the County where disposition occurred.
DH 326. 10/96(Replaces HRS Form 326 which may be used)
(Stock Number: 5740-000-0326-2)
FIELDS, J.
Fields, Julia NO DEED NUMBER PER KIP
ON 8-8-02
UNIT 10B BLOCK 12 LOTS 1-5 & 16-20
Lot 1 - open
Lot 2 - ALexander Sims interred on 1-6-98
Lot 3 - Lillian J. Sims interred on 1-42-1995
Lot 4 - Schwane R. White interred in 1967
Lot 5 - Julia E. Fields interred in 1964
Lot 16 - Mildred B. Lightsey interred in 1965
Lot 17 - Julia Brown interred in 1976
Lot 18, 19 & 20 are all open