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(�/ DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
(2E' Or VITAL STATISTICS
APPLICATION FOR BURIAL-TRAN ,, PERMIT
/14:---- :!..71,
NAME OF First Middle
DECEASED Last DATE Month Day Year
ITypc or print) CLARENCE HOOVER JUDAH _ (DEATH July 7, 1979
PLACE OF DEATH CITY, TOWN,OR LOCATION
COUNTY NAME OF /If not in hospital,give street address)
Indian River Sebastian INSHOSPITTITUTIAL ON oR Roseland Rd.
Attending Physician [ (Name of Medical Certifier) --
Medical Examiners ❑ (Address)
Funeral (Name)
Home Floyd/Strunk Funeral Home, 2405 14th Ave. Vero Beach, Fla.(A32960
Check A El, A completed certificate of death accompanies this application.
One
B ❑ Dr. -was contacted on _ , 19
He has assured me that this death was from natural causes and that he will complete and sign
the medical certification of cause of death.
C ❑ The attending physician was unavailable or this death comes within the Medical Examiners
jurisdiction. The body was released to me by
on — 19.
,,nature) (Fla. Lit. No.)
(Date Signed)
Fu -ral / /
D. ecto,; .�`.�, w 382 July 9, 1979
4URIAL 'TRANSIT-TERM Permit
No, 130-477
PermissronjubeL by:granted to,dispas,e of this-body.by burial, transportation out of state, storage or cremation. For
cremation-tea=lwattinq-_,-period .of AB- hours- after-==death- mt st_=be observed-and-the Medical Examiner's approval must
also be obtained:
". •-> 1 A `ive;day extension-.,of-time for•fifing,the death certificate has been requested and granted.
Signature of Date 9
Registrar (Z_,, „!/f d July Y ' 1979
CEMETERY OR CREMATORY
Method of Disposition Date of
[BURIAL Disposition -t,i:, / ://`,'
❑ CREMATION i •
J —o STORAGE Place of ' (❑ OTHER (Specify) Disposition } :''; t ' " ' __ . ,,,.- A `.7:r ,
•
J
Signature of Sexton _ ,
.or Person in Charge �' ;
This permit;must be endorsed by the sexton or person in charge.(or by the funeral director when there is no sexton)
and returned within 10 days to the local county health department.
HRS Form 326 (1/77)