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STATE OF FLORIDA
ARTMENT OF HEALTH & REHABILITAI�SERVICES 42 7 7^ /C-
VITAL STATISTICS
PERMIT
FOR BURIAL—TRANSIT PERN T
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Stinson DEATH Oc.obe.t 15, 1985
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Lee Cape Conat Inst. Cape Come Ho4p-t tae
3. Name of Medical ® Physician Address
Certifier G. Thomas _Hinz&e, M.D. , ❑Medical Examiner 708 at Pad Picado bevd..Ca Co'tae.F.C. 33904
4. Funeral Home/ Name Address
Direct Disposer Metz Funenae Home. 1306 La6aye. to StAeet, Cape. Coh.at, F.Qoe.irka 33904
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b was contacted on
Box ® G. TaF/OmA� H(IM1�eg 10116/85. He/she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
He. 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
RemOVae�13UJ[(ae medical certification.
Sebaot an. Ceme-terry, Seba tiara, F.Qonada
6. Funeral Director/ Signature Fla. Lic. No./Reg. No. Date Signed
Direct Disposer (\ +
B. BURIAL—TRANSIT PE MIT
Permit No, 667-30S
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. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed
with Local Registrar of the Cou7 in whjch death occurred.
Registrar or /L Date
Sub-Registrar Signature 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
❑ BURIAL ❑ STORAGE Date of Disposition
October 18, 1985
❑ CREMATION ❑ OTHER (Specify)
Signature Person-in-Charge Sexton ) C
or Person-in-Charge ► �Gl,`��-ts.�C_ C • A )„v-
Deborah C. Krages, Citg cnik
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.
FIRS Form 326, APR. 81
(replaces previous editions which may be used.)
A