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Name .46 116 i a t."), t-e 1 h fr
Unit
Block
Lot 1 ci
Date of Mark-out -....
Date of Burial ;4/ / 940 Time 1 0 : 7 C, 14
Name of Funeral Home 'N kori K. S
Authorized by
I
1 . • --__
--
- -
3 7.c.Et
,r?-.... c_/—• DEED P25
John E L. Christena &
General Receipt No. ............... .... Dated.....Jan.23..1974......... Ultuynne L. .Chr,istop9,-
1
, . I
Maximum No. Burial spaces ............
List Price $...75..no...... . 'Bik 2.'6 - Unit 1
niscount $.....::........... Total area in•square feet ................ Lots i6,,,r.,,18,19, ,,,,,2,0
' Osmond
Net Paid $..7.s..on........ Monument permitted ..F.1.3..t............... ,,
c,--c,L., '-, , ...;..-, .
6/7
/5 (Data above this line for City Record only)
6 6 /47
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FRState of Florida, Depar ent of Health and Rehabilitative Services, Vi Statistics f> ,,,,_;°2 p
r117 /° ,J
' APPLI ON FOR BURIAL - TRANSIT PERMIT
Cpl
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Ulwyne Letchworth Christena DEOATH 02/01/96
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Vero Beach Inst. Indian River Memorial Hospital
3. Name of Medical Medical Examiner Address Phone Number
Certifier 2300 Fifth Avenue
Gary Silverman, M.D. 7 Physician Vero Beach, Florida 32960 (407)567-7111
4. Name of Funeral Home/ Address Fla. Lic. No./Reg.No. Phone Number(Area Code)
Direct Disposer 1623 North Central Avenue
Strunk Funeral Homes, P.A. Sebastian, Fl 32958 1228 (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 121 Sherri was contacted on 02/01/96 within 72
hours after death. He/she verified that this death as_from natural c uses, that there was no accident
nor other external cause of death, and that Gary 1 I Verman, M. 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 Sebast i an In state cem-ter , Removal
Final Disposition: -matory - •/county: Indian River — from state I I Donation
7. Funeral Director/ ,ignat - F.E. No./Reg.No. Date Signed
Di pesex- �� 1, -i1G7-t I IC L 2. 02/01/96
B. BURIAL - TRANSIT PERMIT 1228-96-0053
Permission is hereby granted to dispose of this body. Permit No.
❑ 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.
fiegiskrm-er Date 19 C. Date Certificate
Subregistrar Signature Issued: Z I 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
Methods of Disposition: Place of Disposition - -' 4,..,,,•1:,-, . '' '- ,
Ef BURIAL ❑ STORAGE '- 7;: .�-
Date of Disposition =� ,-- _.. :_.�. -
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton 1
or Person-in-Charge) .',. :_-.=- t .__
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`