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STATE OF FLORIDA A ,_Yj /(} // -,
EPARTMENT OF HEALTH & REHABILI E SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Katie M. Stinson DEATH June 7, 1982
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Indian River Vero Beach Hosp. or North US#1 Highway
Inst. g y
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3. Name of Medical EZ Physician 777 37th St. , Suite #B-1 4iress
Certifier Hugh K. McCrystal , M. D. ❑ Medical Examiner Vero Beach, Florida 32960
4. Funeral Home/ Name Address 1950 20th Street
Direct Disposer Cox-Gifford-Romani � P. A.
Vero Beach, Fla . 32960
5. Check a The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ® Hugh K. McCrystal , M. D. was contacted on 6-7-82 . He/ it*verified that
Box this death was from natural causes,that there was no accident nor other external cause of death, and that
Hugh K. McCrystal , M. D. 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./Reg. No. Date Signed
Direct Disposer
J. Charles Gifford #868 June 7, 1982
B. BURIAL—TRANSIT PERMIT
Permit No. 5-127-1982
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 �� Date
Sub Registrar Signatu�p�y—� Issued June 7, 1982
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
Sebastian Cemetery
Method of Disposition: Place of Disposition Sebastian, Fla.
J BURIAL 0 STORAGE Date of Disposition June 9, 1982
D CREMATION 0 OTHER (Specify)
Signature of Sexton
or Person-in-Charge I eciefer
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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