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Unit
Block
Lot
Date of Mark-out ^ ,
---
Date of Burial A Time / 1/1.
Name of Funeral Home_
Authorized by /Cf. .1
f FRis 1 STATE OF FLORIDA ` =
DEPARTMENT OF HEALTH & REHABILI�VE SERVICES /1 / '
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
•
1. Name of First Middle
Last DATE Month Day Year
Deceased
OTTIL.i a FRIEDA THOMPSOAi OF
DEATH FEBRUARY 1, 1989
2. Place of Death City, Town or Location
County Name of (If neither,give street address)
INDIAN RIVER
Hosp. or
VERO BEACH Inst. INDIAN RIVER VILLAGE CARE CENTER
3. Name of Medical ix (Physician
Certifier GARY SILVERMAN, M.D. Medical Examiner Address Phone Number
4. Funeral Home/ Name 2300-5TH AVE. VERO BEACH, FLA 567-7111
cX lei( STRUNK FUNERAL HOME 1623 N. CENTRAL AVE,fresSEBASTIAN FLA Phone 07— 89-1r (Area Code)
407-589-1000
5. Check a ❑ The medical certification has been completed and signed.A completed certificate of death accompanies
Appro- this application.
priate
Box b Q( SHERRY was contacted on 2/1/89
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. SILVERMAN
and sign the medical certification of cause of death. will complete
c ❑ was contacted on
. He/she verified that
, Medical Examiner, will complete and sign the
medical certification.
6. Funeral Director/ ignature
�Ffuneral Director/
,,! Fla. Lic. No./Reg. No. Date Signed
4s-re/ 41672 2/1/89
B. BURIAL—TRANSIT PERMIT
Permission is hereb Permit No. 1228-89-057
y 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 fill the death certificate requested.
Registrar or Date
Subregistrar Signature ,� / / Date Certificate
Issued: 2 1 89 Due:
0
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
Method of Disposition: Place of Disposition Sebastian Cemetery
a BURIAL ❑ STORAGE Date of Disposition Sebastian, Florida
❑ CREMATION ❑ OTHER (Specify)
Signature Sexton )
or Person-in-Charge )
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,Oct 87(Replaces May 86 edition which may be used)
(Stock Number: 5740-000-0326-2)
KROE0LE, Mrs. aul ;!,• ,re,„/
>/. 1), . •
UNIT 1 0.B., Block 2, Lots _121 22,
a/k/a Lot 1
Jr.t..40;