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State of Florida,Depart nt of Health and Rehabilitative Services,Vit tatistics ":y\
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APPLILN FOR BURIAL — TRANSIT PERMIT „,
A. (Type or Print) /1
1. Name of First Middle Last DATE Month Day Year
Deceased Lillian Jewell Sims D OF 01/07/95
2. Place of Death City,Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Sebastian Ins1t016 S. Louisiana Avenue
3. Name of Medical _J Medical Examiner Address Phone Number
Certifier 7744 Bay Street
Noor Merchant, M.D. -7 Physician Sebastian, Florida 32958 407)589-0879
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. aebastian, 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 ❑ i- was contacted on (` 7 91 within 72
hours after death. He/she verified that this dea was f�r n) naturgl. caus.ea, that there was no accident
nor other external cause of death,and that • /!/t62irce(-( 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 �lebast tan Cemetery In state cemetery/ Removal
Final Disposition: matory -na co ty: Indian River n from state n Donation
7. Funeral Director/ ignature F.E. No./Reg.No. Date Signed
Direct Disposer _ 01/08/95
s
B BURIAL —TRANSIT PERMIT 1228-95-0014
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 the d ath certificate requested.
Registrar or Date /_. 7� 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 ,1d*-aYr
® BURIAL ❑ STORAGE Date of Disposition . Q,.,�a i r 99 •
❑ CREMATION ❑ OTHER (Specify) p / ( /
Signature of Sexton )
or Person-in-Charge) .,,7z.,-- .t . (7-4,1-
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)