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•KRO^GLE, Mrs. Paul • 0/i
T ,iIT 1 0.R., Block 2, Lots 21 22, 23 21 25 ✓
30, 37, 3 , 39, 40
a/k/a. Lot l
STATE OF FLORIDA ;l
•ARTMENT OF HEALTH & REHABILITAT•SERVICES
VITAL STATISTICS
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APPLICATION FOR BURIAL—TRANSIT PERMIT U I ,, � , I
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A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
JOSEPH TRELEY THOMPSON DEATH August 11 , 1984
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 Physician Address
Certifier Thomas Jackson, M.D. ❑Medical Examiner 777 37th Street. , Vero Beach
4. Funeral Home/ Name Address
Direct Disposer Strunk Funeral Home. , 734 N. Central Avenue. , Sebastian
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
Pilate h
Box b LJ Ruby (sec'y) was contacted on 813 He/she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
Dr. Jackson — — will complete, and sign the medical cei titication of
cause of death.
c ❑ was contacted on . He/she verified that
Medical Examiner, will complete and sign the
medical certification.
6. Funeral Director/ Si nature el Fla. Lic. No./Reg. No. Date Signed
Direct Disposer
/'/' August 13, 1984
B. BURIAL—TRANSIT PERMIT 1228-84-255
Permit No.
Permission is hereby granted to dispose of this body.
"rE 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 Co my in which death occurred.
Registrar or Date August 13, 1984
Sub-Registrar Signature_ /A-C" Issued
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
VI BURIAL El STORAGE Date of Disposition August 15, 1984
0 CREMATION 0 OTHER (Spe ' -
Signature of Sexton ) i / / / U ! -mot.-�- --<` _
or Person-in-Charge ) . .��1—O�Q-/-- c
Deborah C. Krages, City Clerk
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.)