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Name G E k Tk U !.I 7el. rY3z 5
Unit T
Block 3 J
Lot
Date of Mark-out_ / _ // U
<: 7
it
Date of Burial �' -i•; /4, 1'
Time
0 iY`?
Name of Funeral Home ,-,> d i Li f k,,,
Authorized by
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Ll'S State of Floridalpartment of Health and Rehabilitative Serve Vital Statistics U / n'
APPLICATION FOR BURIAL — TRANSIT PER
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
GERTRUDE RIMES DEATH JULY 25 1990
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 I Medical Examiner Address Phone Number
Certifier
NOOR MERCHANT, M.D. ,/ Physician 777 37TH STREET, VERO BEACH 567-2332
4. Name of Funeral Home/ Address Fla. Lic. No./Reg. No. Phone Number(Area Code)
liOren-t-Bispeser
STRUNK FUNERAL HOME 916-17TH STREET, VERO 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 m LIZ was contacted on 7/2 6/90 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 that DR. MERCHANT 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 CEMETEr. In state cemetery/ Removal
Final Disposition: crematory - name/county: INDIAN RIVER n from state n Donation
7. Funeral Director/ / Signature F.E. No./Reg. No. Date Signed
hJ nep0SE'r 2)1. .253 7/26/90
B. BURIAL — TRANSIT PERMIT 130-90-403
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.
Ftcgictrar er A . nQ Date
7/2 5/9 0 Date C tiff to
Subregistrar Signature r\ Q Issued: Due: / 9/90
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 0..4i._.. .
II BURIAL El STORAGE Date of Disposition 7 0.7 /
❑ CREMATION ❑ OTHER (Specify)
I Signature of Sexton ) /
or Person-in-Charge 1 7 / • //.. z
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 he used)
(Stock Number 5740-000-0326-2)
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