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Name
f 0. • .0 • ,
Unit 2t:
7-
/
Block 33
Lot 1 (4'
Date of Mark-out 4/7794/
Date of Burial •
Time .,
Name of Funeral Home : : ' '
Authorized by ---
I
FRS State of Florida,Department of Health and Rehabilitative Services, Vital Statistics y� 7
1 117 APPLIC FOR BURIAL — TRANSIT PERMIT
II / - b! L/ ��
�'' '�' `. ter'
A. (Type or Print) C
t
1. Name of First Middle Last DATE Month Da Year
Deceased OF
Jay F. Thompson DEATH May 27, 1994
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Roseland Inst. Sebastian River Medical Center
3. Name of Medical _I Medical Examiner Address Phone Number
Certifier 7744 Bay Street, Suite #2 (407) 589-0879
Noor M. Merchant. MD xx�Physician Sebastian, FL
4. Name of Funeral Home/ Address Fla.Lic.No./Reg.No. Phone Number(Area Code)
Direct Disposer 950 Malabar Road, SE
Palm Bay Funeral Home Palm Bay, FL 32907 FH-1422 (407) 724-2224
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b ® Liz was contacted on 06/03/94 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 Noor Merchant. MD 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 In state cemetery/ Sebastian Cemetery Removal
Final Disposition: ird crematory -name/coun-vndi an River n n
from state Donation
7. Funeral Director/ Sign re F.E.No./Reg.No. Date Signed
Direct Disposer _∎—
)1 �\((2n 06/06/94
B. BURIAL —TRANSIT PERMIT
Permission is hereby granted to dis.:se of this body.
Permit No. FH-1422-2894
® 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 Regi rar of the County in which death occurred.
❑ No extension of time for filing t d ath certific requested.
Registrar or
!•✓9 Date Date Certificate
Subregistrar Signature Issued: 06/06/94 Due: 06/16/94
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 2174
Methods of Disposition: Place of Disposition SPhaGti an CPmPtPry
U BURIAL ❑ STORAGE Date of Disposition 6/ 7/91
❑ CREMATION ❑OTHER (Specify)
Signature of Sexton ) ,/
or Person-in-Charge) /31 . � 9, -
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 be used)
(Stock Number.5740-000-0326-2)
i