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N S-4---to- STATE OF FLORIDA _ a / .(3. ,3d y
"'DEPARTMENT OF HEALTH & REHABILI ,VE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
JOIE M. HOLTZCLAW DEATH April 7, 1983
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. :Indian River Memorial Hospital
3. Name of Medical a Physician Address
Certifier Joseph A. Hill, M.D. E]Medical Examiner 2300 5th Avenue. , Vero Beach, Florida
4. Funeral Home/ Name Add ess
Direct Disposer Strunk Funeral Home. , 916 17th Street. , Vero Beau, Florida 32960
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b to JoAnn (secretary)
Box was contacted on 4/7/R3 He/she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
Dr. Hill 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. Funeral Director/ Signature Fla. Lic. No./Reg. Na. Date Signed
Direct Disposer d(..,./
1672 April 7, 1983
B. BURIAL—TRANSIT PERMIT 1228-83-103
Permit No.
Permission is hereby granted to dispose of this body.
a, A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or Date
Sub Registrar Signature/AU-14 Issued April 7, 1983
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
Signature , Medical Examiner Date
0
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
Method of Disposition: Sebastian Municipal Cemetery
P Place of Disposition
iURIAL E] STORAGE Date of Disposition April 9, 1983
❑ CREMATION [I] OTHER (Specify)
Signature of Sexton ) /) / G�
or Person-in-Charge ) C. ;dQ/"Q/
CITY CLERK fg-4)-
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 County Health Department in the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)
A