Loading...
HomeMy WebLinkAbout1-33-20 • iS .I 'i"- .,5 -01 r ; . w. . . _ _,,,; _ _ ir,tite.„, • . .... , , .. ____ _ ► g — + 9,, O C ' - 1 t II ''■/212../1;.. T"'" .. ,' I itillitilw/S2".734151t _ - _ . r' Al4 t . ... . _. .-_ 1 •" Varna F.Champ I r MY COMMISSION 4 CC735787 EXPIRES t. �:� July 10,2002 ,',s pc q .,ONDED THRUTROY FAIN INSURANCE,INC . .„,„ , b , „, O, / _ .., c . .. . . - ... , ...... • .•• ... . ... — . . . . . . . . . . . .. . .. • • ..•., . ' • ..,• . . • . . .••. .. • . . „ ,: . • . .. -.., . ' •s • / 1 :44 --Si \D . %cr. I c-c) • ).... I 7 a i "■......0 ,:. ,....3 .....1, 1 . . J.) C.,..) ...c* . . . • .- .. .... •. .. — • 1 i 1 I I a g. Lam_.._,. _ �' h..�' PLrMo x sYM. /AA r `r NaeA �J UYr�' � r. D. e? I t e ks \ X98'3 19 MS' t1SS. '.4-2 0 r I, 7 /v i3 ? iy ? .r' .- /c r!A'I/ - 1� - `f ..e I r,io µdo K)'A „ lo' n k )o . 1., 5a1.rl 501.4 ';S.oLC, St,1-,h .. ta:7�.''A .. tMIlli t ` RE wy%: iL �) filakf12- ii SSA 3a 1 �F � ar.• .. , T,�zC _ 9 7 saxes ,, ^a�c�y 0 1 '•` • . 1.. ,ASo"- y.' /Z e1.0 / e1.p 50 1,.4 , .. 3/AitMq 31 /� � ���� J` l.0 /,- -/ '4'-'-' 9cive,1ro, ULIN� .1`_`_ r D N p c �c ` !tr U—iG2�o2o �PIL `r' 'o ( • L _ 1 .,71f y 57 Ji.. `I _. )!/, N/A 14/7 . 0/0 04/A `K/o "/ I Ox I _ . Cb /91Cf 5o1.a , 5- k;, Sr,l,� , 5 el,o .', .e r oi. 4 _ 5;i1. � /9yG 19 .y� ..._:.... :__. /2 ((,5, >?5rD _ Name w /L Li/kill O/Yt (co 3 -X'RcS Unit Block 3 3 Lot a(J Date of Mark-out _ O Date of Burial y Q OU ' Time Name of Funeral Home (-51-7 /-(A// - (V e j Authorized by I FLORIDA DEPARTMENT OF 63-3 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 William J Thompson Death 5/20/02 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 Address Phone Number Certifier John Suen, M.D. 1355 37th Street, Ste 302 fMedicalExaminer [Physician Vero Beach, FL 32960 (772) 770-4888 4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code) Establishment 916 17th Street Strunk Funeral Home Vero Beach, FL 32960 0130 (772) 562-2325 5. Check a. ❑ The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b. © was contacted on 5/21 /02 • He/she verified that this death was from natural causes,that there was no accident nor other external cause of death, and that Dr. Suen will complete and sign the medical certification of cause of death within 72 hours. c. 0 was contacted on He/she verified that , Medical Examiner,will complete and sign the medical ce ific tion of cause of death within 72 hours. 6. Funeral Director/ S n ur F.E. No./Reg. No. DaterSign d Direct Disposer ,24a3 c /zit o a. B. BURIAL -TRANSIT PERMIT {{{ Permission is hereby granted to dispose of this body. Permit No. 0130-02-0241 ❑A 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. NNo extension of time for filing the death certificate has been requested. Registrar or , . A. Date Date Certificate Subregistrar Signature , / , + , Lid.; Issued: /bZ_. Due: ;j `] �2.... 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 0BURIAL 0STORAGE Date of Disposition 0CREMATION OTHER(Specify) Signature of Sexton or Person-in-Charge 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 01-1 326,8/97(Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer (Stock Number: 5740-000-0326-2) Pink: Local Registrar