HomeMy WebLinkAbout1-19-36 - • -
Name 47 Hdiez E 5, 5 4 V 6.7
7-
Unit
Block /
Lot 3Co
Date of Mark-out
Date of Burial 5-75- 6 a
Time // ; 0 o
Name of Funeral Home 6 r' 4'4 41e
Authorized by
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FRS STATE OF FLORIDAr%
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VITAL STATISTICS /J
��I�^�,°1�.,11,",�K°"" APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
CHARLIE S. SAVAGE DEATH MAY 2, 1988
2. Place of Death City, Town or Location Name of (If neither,give street address)
County Hosp. or
INDIAN RIVER FELLSMERE Inst. 148 MAGNOLIA STREET
3. Name of Medical 44 Physician Address Phone Number
Certifier FARHAT KHAWAJA, M.D. D Medical Examiner 7754 BAY ST. SEBASTIAN, FL 589-3000
4. Funeral Home/ Name Address Phone Number (Area Code)
DRIOUDIWUCKr STRUNK FUNERAL HOME 1623 N. CENTRAL AVENUE SEBASTIAN, FLA 407-589-1000
5. Check a ❑ The medical certification has been completed and signed.A completed certificate of death accompanies
Appro- this application.
Bte
Box ox a a TERRY
was contacted on 5/3/88 within 72
hours after death. He/she verified that this death was from natural causes, that there was no accident nor
other external cause of death,and that DR. KHAWAJA _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
air P --__' / zl 4 /e 7L 5/2/88
B. BURIAL—TRANSIT PERMIT Permit No.1228-88-218
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 as undue hardship
would result from filing within the normal time limit.If the certificate cannot be filed within this extended time limit,a "Funeral Director/Direct
Disposer Report" will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for fil' g the death certificate requested.
Registrar or -n Date Data Certificate
Subregistrar Signature f� l�rl.r�►� Issued: 5/2/88 Due:
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/--ll/2 &..,"JLt .
Ij(BURIAL ❑ STORAGE Date of Disposition ...S-- J`4j--
0 CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person-irrehrdFge) 770 Ci 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,Oct 87(Replaces May 86 edition which may be used)
(Stock Number: 5740-000-0326-2)
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UNIT 1 O.B., Block 19, Lots 21, 22, 23, 24, 29
c31 i , 38, 39, 40
a/k/a Lot 1 ?`,
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Flock 19 Lots 21, 22 23, 2) , 25 unit 1 0.8.
a4),E ► 38, 3), Lo
a/k„ a Lot 1
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