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HomeMy WebLinkAbout1-28-24 Name G re-e: G Unit Block 40". Lot Date of Mark-out C i - I Date of Burial g- - I Time Name of Funeral Home 6i-R.L1r■,,, Authorized by SHEET NO. L t-••..•any�C � Y o.,_:,.{ "7"......w . RTEARTMINS G _. -_._ i± f __ ∎tiJi',"...C"' - y CREDIT �. LIMIT • 9 Afw, X ? " '� `�o < -1-4.0,r5 . +;.g° ` r ::Acfhearl: 1 (� -) Tiue ie s • 'Vaikg. \/ v.00 ].3S'• ' 1.03 r © ,t .r n r�/ M • �.� �.w�r it sM u u (� .7• ? 4 I A/ lig ffigli /Po . k ? r r �o ! ILS ( Mfi� K o , N/o a I . :iy7� ��...,,.� , `. sorb 1 //A �a�°•• 31 .» It ___ .] 1. ., ' V 'R/-I' . ......e, /l N y \ 7 :,01 R ��''• �otn 1 C� S a ��4. 5 l . � Vi i' -_ J. .. •1Y , II y; 0 hlk W3- t r �M .., I v .' A@@.y V :,v44Y`R -''''4.'' ''''''''':5=')'-'3 i T. !'- Y'--F'FI�+Y A.[ � )',-24,:5,,-,, .1 * ', /� p .. 'W_. t " ^k tArg ..'^lndC� -. ,-- t'-"6-' - 'LTSi ....-- - .-.. .:4. .dt4v.._.L. xk}a"s...L' �r --u L.: lti rk 3'• d r..� .�.. State of Florida,Department of Health and Rehabilitative Services, Vital Statistics / �y / ✓ 6':-/--- APPLICAle FOR BURIAL — TRANSIT PERMIT • A. (Type or Print) _ 1. Name of First Middle Last DATE Month Day Year Deceased Gregory Clarence Jttdah DEATH 08/18/91 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Indian River Sebastian Inst548 Cross Creek Circle 3. Name of Medical I Medical Examiner Address Phone Number Certifier 7744 Bay Street Noor Merchant, M.D. X I Physician Sebastian, Florida 32958 (407)589-0879 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 X T.ydee was contacted on 08/19/(11 within 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 thatNoor Merchant, 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 o8ebastian Cemetery In state cem: -ry/ Removal Final Disposition: ' IIII crematory ame/county: Indian River ❑ from state n Donation 7. Funeral Director/ '' Signt u F.E. No./Re -ode- Date Signed 1672 08/19/91 B BURIAL — TRANSIT PERMIT 1'2`28-91-0372 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 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 fill 1 the death certific to re sted. Registrar or if` /6:41)"_ ) G` Date i /'Q 0/ Date CertificateE / G//Subregistrar Signature f�l_x /c Issued: / /-- / 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 -®5-4 - Z T 1e y • • BURIAL ❑ STORAGE Date of Disposition of /r?/ ❑ CREMATION ❑ OTHER (Specify) Signature of ) ��. or Person-in-Charge) 7 9 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) •