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Name id Al C I. KE
Ur.t
Block C
Lot
Date of Mark-out
Date of Burial 0/9/ Time 1 -00 p M -
Name of Funeral Home
Authorized by
r /j,14)2(- -t9 / 7
C4_
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402e
[Ff ] State of Florida,Depait of Health and Rehabilitative Services, Vtatistics A i✓APPLICHu ION FOR BURIAL - TRANSIT PERMIT /
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Hazel E, OF
}ulcer DEATH 05/01/91
2. Place of Death City, Town or Location Name of (If neither,give street address)
County
Hosp. or
Indian River Vero Beach Inst. Veto Beach Care Center
3. Name of Medical I Medical Examiner Address Phone Number
Certifier
2300 5th. Avenue
1,-1 ., Vann, M.D. X]Physician Vero Beach, Florida 32962 (407)567-7111
4. Name of Funeral Home/ Address Fla. Lic.No./Reg.No. Phone Number(Area Code)
Direct Disposer 1623 North Central Avenue
Struiil I I 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 k] Rarhara
was contacted on 05/(}1/91 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 E.J. Vann, 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 Sebastian Cemetery In state cemetery/ Removal
Final Disposition: X I cr matory -nay e'unty: Indian Riven n from state n Donation
7. Funeral Director/ gnat�re F.E. No./Reg.No. Date Signed
Direct Disposer A A�t — _ 672 05 'Ul `91
B. BURIAL - TRANSIT PERMIT
1228-91-0215
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 fili the death certificate reque d.
- Re Istraror a e r ` Date Date
Certificate Signature 1.../ 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 .61i1.1. ....:. (7..€41,7,-"b4-4.7
® BURIAL ❑ STORAGE Date of Disposition 6--- (a•- 9/
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ) ,/ . ci_L, t or Person-in-Charge) n -4/4 9. -
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.
I-r RS Form 326,Feb 89(Replaces Oct 87 edition which may be used)
(Stock Number:5740-000-0326-2)