HomeMy WebLinkAbout1-10-33 `aa
J Jl
(:-/-) _::."\--..ei
•
v'
—may.' j
• �
. G ■ 4
lc-
`� _
I A '3 s, r, -�1 v•
�"1 �'' 2
o
•
.. t _ -5.-
C
W \ e z- \ -a --\ "7".,A)"7".,A)
Q-s--
�� , QO o GI -0 U►
‹ .
•
Z. ' -S-UN
-I ��-,
'.1-1 p�
JD cc\ Z
d 4 ` n�
z. IN
.!. . -?..,(..N .- -4;2) t_ .. . . . ....
7p
:.:.Z •v o
-4q3_
,
i O
,, ..•
v
•
g... . U'
1
C N
. r_.
to
A.i. : . ,..
.-t ._ :. :.1... . .,
.
td
i_.
0
0
.....(—
. . ,
i,krk-rCikk . .-
\Q >O c
cl-
co
l4 ¢t WN .
,_.. IN"''l
� � r ' V
o`` w�
ikA iv
•
V
•
/j1
STATE OF FLORIDA 0EPARTMENT OF HEALTH & REHABILITOE SERVICES �. /V (, i (7./6�
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
ILAI F. STINSON DEATH April 10, 1983
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
St. Lucie Ft. Pierce Inst. Abbiejean Russell Care Center
3. Name of Medical 13 Physician Address
Certifier Maltby F. Watkins ❑Medical Examiner 308 South Eighth Street, Ft. Pierce, FL
4. Funeral Home/ Name Address
ihrXtter P.A. , 1950 20th St. , Vero Beach, FL 32960
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ® Maltby F. Watkins, M.D. 4/11/83
Box was contacted on . He, ffe 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
medical certification.
6. Funeral Director/ Signature Fla. Lic. No./ Signed
Date S gned
DARtAlblckStr
J. Charles Gifford #868 April 11, 1983
B. BURIAL—TRANSIT PERMIT �
Permit No.�-101-1983
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 the Local Registrar of the County in which death occurred.
Registrar or
APP" Date April 11, 1983
Sub-Registrar Signaturet� _ _ !� �.. • />ii:�� 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 April 11 , 1983
0 CREMATION OTHER (Specify)
Signature Sexton ) / !
or Person in in Charge ► Ac-&TG�V (.
Deborah C. Krages (iv
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.)