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Name 1 /f tI€ E SA W A S S Q W
Unit .
Block 3 1
Lot 2
Date of Mark out 9 i 6
1 9 ; 00r4`n
Date of Burial .�� / Q �o Time
Name of Funeral Home S k U K
F , 1�'
f.
Authorized by -- f
r
STATE OF FLORIDA
RTMENT OF HEALTH & REHABILITATIIDERVICES
VITAL STATISTICS i
APPLICATION FOR BURIAL—TRANSIT PERMIT 0 I
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
THERESA N/M$N WASSON DEATH SEPTEMBER 27, 1986
2. Place of Death City, Town or Location ' Name of (If neither, give street address)
County Hosp. or
INDIAN RIVER ROSELAND Inst. HUMANA HOSPTTAL—SEBASTAIN
3. Name of Medical [i Physician Address
Certifier Farhat Khawja. M.D ❑Medical Examiner 7754 Bay Street Suite 7 Sebastian, Florida
4. Funeral Home/ Name Address
Direct Disposer STRUNK FUNERAL HOME . 734 N. CENTRAL AVENUE SEBASTIAN, FLORIDA 32958
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ® Pat was contacted on 9/29/86, He/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
Dr. Khawja 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.
Signed
6. Funeral Director/ Signature Fla. Lic. No./Reg. No. Date Si 9
2088 SEPT. 29. 1986
B. BURIAL—TRANSIT PERMIT Permit No. 1228-86-371
Permission is hereby granted to dispose of this body.
El A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and
granted. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed
wi the Local Registrar of the County in which death occurred.
Registrar or �w �C� IDssued SEPTEMBER 29, 1986
Sub-Registrar Signature ���,KKKK
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
Method of Disposition: Place of Disposition
❑ BURIAL p STORAGE Date of Disposition
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ) l
off;or Person-in-Charge ) _....41 imi�-r.d! ` "„i iii •
This permit must be endorsed by the Sexton or person-in-charge (or by /e Fun r I Director/Direct a isposer when there is no Sexton)
and returned within 10 days to the local County Health Department in the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)