HomeMy WebLinkAbout1-24-33 •
Name / t
OA)
Unit
Block 2q
Lot
Date of Mark-out 3 /11 44;
Date of Burial 1 95
Name of Funeral Home kit AikS
Authorized by
[�]C State of Florida,Departmlf Health and Rehabilitative Services, Vital*tics /� :22 _
��71 APPLICATION FOR BURIAL — TRANSIT PERMIT / / /; /i
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Ze l ma McPhearson DEATH 03/10/1995
2. Place of Death City,Town or Location Name of (If neither, give street address)
County Hosp. or
Saint Lucie Fort Pierce Inst.Lawnwood Medical Center
3. Name of Medical J Medical Examiner Address Phone Number
Certifier 1900 Nebraska Avenue, #3
Steve Beiser, M.D. XiPhysician Fort Pierce, Florida 34950 (407)464-0033
4. Name of Funeral Home/ Address Fla.Lic.No./Reg.No. Phone Number (Area Code)
Direct Disposer 916 17th Street
1 Strunk Funeral Homes, P.A. Vero Beach, Fl 32960 130 (407)562-2325
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b - ChPry1 was contacted on 03/10/1995within 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 Steve Beiser, 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. Place of Sebastian Cemetery In state cemetery j Removal
Final Disposition: : atory - : . ,aunty: Indian River n from state n Donation
7. Funeral Director/ -fgnature F.E.No./Ft ag-hio. Date Signed
Direst-Dispeeer Agrosirier 1672 43/1011995
B BURIAL— TRANSIT PERMIT
Permit No 0130-95-0137
Permission is hereby granted to dispose of this body.
"E1 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 filing the death certificate requested.
4iiiigistr-arax, M Date f e Date Certificate//��,�
Subregistrar Signature Issued: 3 I 4 s 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 /I
Methods of Disposition: Place of Disposition be-4.—, z 4-7
1 BURIAL ❑ STORAGE Date of Disposition '-l't-)c..A ty I (c'l(1 S'"
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person-in-Charge)� .. 'i. s . "lr 1 •
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 HRS County Public Health Unit in the County where disposition occurred.
HRS Form 326.Feb 89(Replaces Oct 87 edition which may be used)
(Stock Number:5740-000-0326-2)
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