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STATE OF FLORIDA •
ticcPARTMENT OF HEA LT & REHABIILITATWSERVICES G=am 'J /6 1/ /t�
VITAL STATISTICS •
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print) '
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Saimi Fredrika Salmela DEATH January 3, 1985
2. Place of Death City, Town or Location Name of (If neither, give street address)
County 'Hosp. or
Indian River Vero Beach, Florida Inst. Indian River Memorial Hospital
3. Name of Medical n Physician Address
Certifier Dr. Muhammad Farooq ❑Medical Examiner 777 37th Street Vero Beach, Florida
4. Funeral Home/ Name Address
=#oweePliispe r- Pottinger & Son Funeral Home, Inc. 1200 South Indian River Dr. Sebastian, FL
5. Check a a The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
pi iate b ❑ was contacted on . He/she verified that
Box from natural causes,death was f I u , t at h there was no accident nor other external cause of death, and that
will complete and sign the medical certification of
cause of death.
c El cause
contacted on . He/she verified that
, Medical Examiner, will complete and sign the
2 m•dical cer fication.
,� #2368 January 4, 1985
6. Fu eral Director/ ignature Fla. Lic. No./Reg. No. Date Signed
L►Dta}ruaar
•
B. BURIAL—TRANSIT PERMIT 759-588
Permit No.
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 1�A��p � � ` sate /�, , �f I tel
Sub Registrar Signature,lL�1L�!4'- �� i„' .4 l`I1 I • ',ued a/s` (. 71 I 74")
•
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 January 7, 1985
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton n '
or Person-in-Charge 1 e 4 I /`/y► r/ ' /
DEBORAH C. r G S, CITY
CLERK
This permit must be endorsed by the Sexton o person-in-charge (or the Funeral rector/Direct Disposer when there is no Sexton)
and returned within 10 days to the local County Health Department i the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)