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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) •• .. ....'.: ,. , t t. - ........-.......-......--_ --1 1,,) ■ o t'. ..A k r ---..... = r °' 0 . V Ir' • I : t.,),,„. .,. t t, '0 '."--. !, ,, ..', •. , • • c'...r d.t....,L! , L-,-........ I '-- r• C.) ...eda-. "./ LA. N.. , ■ii;''' , C...: -r- •-- ' • ,..• , .; •—.....„.. t ..... ,., J ',......,. r" v (....1 ''.;•, ..' a li.... ', -, CY ----\,,,■ " Lb . -- D _-1, -"S• t...... _ 0 ..,..0 ) N's ...-- --.. . ■...7 ■ .S." . --k- rc (.11 } c...,...7.. ...c....2 ii......z." ‘.-■..... . ! •- • ...--".. '-' \ r' t7 ‘,71. I d....1,14.4....-71.4- ........—_—__ 0. ‘7..- N vi.t.4... ■.:.,-^‘ ,ci Ci t&'■ N. ,S, kJ\ „...) ..".... Ci Or ' i • , -- (.11k.... - , \ ._ . —. I •', .., . ., . , dr. --®gt r:-.: c.. „,.... _A.) . ......, _. r P 7,ZN _ -.... ---'`• )- k./ ,. • c.i tA, !ci \; _ c ..-- ,_.., : LA ' .,"...,1/4-\t”.•'., 9,,yeLttlt ■110 .. ----- t ..:7 — I %,.. irks lc, • L.. ,...., , .) ---- .. \Az.,...- .; ,. , 1 rry® k ', —,.-e:... - ,..1 k • .—.._ '\c.'' '') "..... --4,-.ft '-' ,.., i-7/ . ,,.::_x. :- • 0, \ •,.k, 7, ••••• .0 t ..1 •.... • _& ,.,N.- ViCU us I 4 _..- — • ..- -...., ' Z • ----. c'C _ t----Z (_0® \\ • ,,, -., . r 0 ..:,_ -I. ..A N 1-• \.:„›.• ,...,) .7„r.p. . ck, ‘.. -., ---------'---. -'' ---------------------.....,----_-____. __.........":- . . ...... ....,...(''). . .... . ' .v(Jvv\-•6:./1":1". 0 ‘, 0 4 ' k..._..1..• .0.\ 0 . s_ :- -.... •0■_. ..• r V AA ' d s•ks 1-, . • tl R5.P6 e4.bet.1's FAME& -a ......, UJ ,,) /.-( f \ ? C 3: -i C r- Z. 7C iv ' \.1 al n) rl .4 kot up ,ag '... .....1' 11 f, V). r• .Z"'", .A., 1 M V 7c. .•-•• ,',,' IL 1 , I) P 7x...D: I 441,\A .. . .. C. ...V. ..- ik,0.03 ‹..-.........--.