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Date of Burial h',' ' ,/ 6 UJ Time Oo /0 in
Name of Funeral Home 6-7-/cu --
Authorized by
LLOYD,
_UNIT 1 (?.B., Block 20. ?pots l 2, 3'11,.,, 5 19
20
7� 8
a/k/a Lot 2
UNIT 1, BLK. 20, LOTS 1 & 2
DOSS HALL interred 1965 - Lot 2
MINA HALL interred 11/6/86 - Lot 1
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STATE OF FLORIDA
S EPARTMENT OF HEALTH & REHABILITJE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT /
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased MINA MAE HALL OF NOVEMBER 3, 1986
DEATH
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
INDIAN RIVER FELLSMERE, FLORIDA Inst. 10650 STATE ROAD 507
3. Name of Medical ® Physician Address
Certifier FARHAT KHAWJA, M.D. ❑Medical Examiner 7754 BAY STREET SEBASTIAN, FLORIDA 3295E
4. Funeral Home/ Name Address
1EX STRUNK FUNERAL HOMES 734 NORTH CENTRAL AVENUE SEBASTIAN, FLORIDA 32958
5. Check a D The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ® THERESA was contacted on 11/4/86 , He/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
DR. KHAWJA 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/ Si Fla. Lic. No./Reg. No. Date Signed
/j1112,
2088 11/4/86
B. BURIAL—TRANSIT PERMIT
Permit No. 1228-86-417
Permission is hereby granted to dispose of this body.
La 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 � J Date 11/4/86
Sub-Registrar Signature �. .dLS 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
BURIAL STORAGE Date of Disposition
CREMATION OTHER (Specify)
Signature of Sexton ) / � ,AO-
l / -
or Person-in-Charge ) 0_
This permit must be endorsed by the Sexton or person-in-charge (or by t Fune ieirector/Direct Disposer when there is no Sexton)
and returned within 10 days to the local County Health Department in the County ere disposition occurred.
FIRS Form 326, APR. 81
(replaces previous editions which may be used.)