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MY COMMISSION#CC735787 EXPIRES
July 10,2002
47 ANDED THRU TROY FAIN INSURANC.E.INC
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Name ?"1 NC gS 771/61/91/Qs a Ai
Unit
Block 33
Lot /9
Date of Mark-out /2/2 2-//a/
Date of Burial / 2_ 7.2 T/Q 0 � d 0
Time
Name of Funeral Home 74-7e•-• L(, X S Ve .`.-0
Authorized by , ,
CITCITY OF
Y CLERK SAOFFICE
0 8
RECEIPT
Name Strunk Funeral Home
0 Cash
Date 12/27/01 *I Check# 9306
Amount Paid
001001 208001 Sales Tax
001501 322900 Garage Sales
001501 341920 Copies/Bid Specs.
001501 341910 LDC/Code of Ordinances
001501 362100 Community Center Rent
001501 362100 Yacht Club Rent
001501 362150 Non Taxable Rent
001501 343800 Cemetery Lots
601010 343800 Cemetery Lots
Lot/Niche ,Block ,Unit
001501 369400 Interment Fee
001501 369400 Weekend Service 150.00
680800 220681 Yacht Club Security Deposit
680800 220682 Community Center Security Deposit
680800 220683 Riverview Park Security Deposit
. JW
Initials
Total Paid 150.00
White—Dept.of Origin• Yellow—Finance •Pink.Applicant
FLORIDA DEPARTMENT OF
HEALT State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL-TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
Frances Thompson Death December 20, 2001
2. Place of Death City,Town or Location Name of (If neither,give street address)
1060 27th Street
County
In Vero Beach, Florida32960
Indian River Vero Beach Inst.t. or
3. Name of Medical Address Phone Number
Certifier Dr. Michael H . Vu 787 37th Street, Suite E100
nMedical Examiner nPhysician Vero Beach, Florida 32960 561-299-4255
4. Name of Funeral Home/Direct Disposal Ay b drass Street Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment Vero Beach, Florida 32960 0130 561-562-2325
Strunk Funeral Home
5. Check a. 0 The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. ® Robin was contacted on December 21, 2001 .
He/she verified that this death was from natural causes,that there was no accident nor other external cause of death,
and that Dr. Michael H. Vu will complete and sign the medical
certification of cause of death within 72 hours.
c. LI was contacted on . He/she verified that
, Medical Examiner,will complete and sign the
e al ceh ication f cause of death within 72 hours.
6. Funeral Director/ lit atu F. IoJ ate Signed
Direct Disposer h , C 2 1�
t
B. BURIAL- TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No.O1 30-01-0601
five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours.
❑No extension of time for filing the death certificate has be: -i nested. ,1/ )) 3 C'1vv(
Registrar or Date Date Certificate
I December 21 2001
Subregistrar Signature �' • .;.-4., Issued:
Due:
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number: Date
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 ❑STORAGE Date of Disposition
fCREMATION n OTHER (Specify)
Signature of Sexton
or Person-in-Charge J}
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 County Health Department in the county where disposition occurred.
Distribution: White: Cemetery or Crematory
DH 326,8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number 5740-000-0326-2) Pink: Local Registrar