HomeMy WebLinkAbout1-10-09 Name 7 T 5
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Unit e.
Block 1 0
Lot 9.
Date of Mark-out 0 /. f& 5-
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Date of Burial ` = / 9 f 8 � Time /r; O }
Name of Funeral Home
Authorized by
STATE OF FLORIDA Ai 4 %i /J / ,' L//
fikPARTMENT OF HEALTH & REHABILIT E SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
John L. Stinson DEATH October 1, 1985
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 t] Physician Address
Certifier Hugh K. McCrystal M.D. D Medical Examiner 777-37th St. . Vero Beach, Florida
4. Funeral Home/ Name Address
DX13101 l'c lAXXX Cox-Gifford Funeral Home, 1950 20th St. , Vero Beach, Florida 32960
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate XO Dr. McCrystal 10/1/85
Box b y was contacted on 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 D was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
medical certification.
6. Funeral Director/ Signature Fla. Lic. No./Reg. No. Date Signed
Jame T. 4 James T. B •da ,i;• i � ,,' / 1696 October 1, 1985
B. , BURIAL 1AtANSIT PERMIT 1423-235-1985
Permit No.
Permission is hereby granted to dispose of this body.
ItA 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 (4 sci Issued October 1, 1985 _cya
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
AD BURIAL 0 STORAGE Date of Disposition. fctriher 4, 1985
0 CREMATION 0 OTHE' •.ecif )
/
Signature of Sexton ) / ,�A„
or Person-in-Charge ) • l� -62-Deborah C. Krages� ity 1er:
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.)
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Block 10 Lots 1, 2, 3, 4, 1 Unit 1 0.B.
16, 17, 18, 19, 20
a/k/a Lot 2
Dr.
Rose, Mrs. Elizabeth & Schumann