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Lot 474, 37
Date of Mark-out 3/4? /?'0
Date of Burial 3//d /,0 Time �• 00 p rn
Name of Funeral Home ly,., '/. y //0/3
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Block 35 Lots 37, 38
Unit., 1
Reynolds, James B. Deed X201
Reynolds, Mrs. Anna S.
P.O. Box 4121 H (Indian River Dr. near Judahls)
Sk'astian, Fla.
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Fr- :3 State of Florida,Ailment of Health and Rehabilitative Service�al Statistics+ :_5.3
APPLICATION FOR BURIAL — TRANSIT PERMIT ' /
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
JAMES ELMER REYNOLDS DEATH March 6, 1990
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Indian River Sebastian Inst. Humana Hospital
3. Name of Medical I Medical Examiner Address 407-589-8992 Phone Number
Certifier
George Mitchell, M. D. XIPhysician 13855 US #1, Ste #4, Sebastian, Florida
4. Name of Funeral Home/ Address Fla.Lic. No./Reg.No. Phone Number(Area Code)
ilk.E4XXI,VOXEXXX 3015 Okeechobee Road
Haisley-Hobbs Funeral Home Fort Pierce, FL #904 407-461-5211
5. Check a Ig. The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b ❑ was contacted on 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 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: Cemeter [crematory -name/county: Indian River n from state n Donation
7. Funeral Director/ ignature F.E. No./Reg.No. Date Signed
)fix xxi Xafff /// ,cif /A� #1406 3-8-90
B. BURIAL — TRANSIT PERMIT
Permission is hereby granted to dispose of this body.
Permit No. 904-4313
❑ 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 filin the death certifica req ted.
Registrar or p Date Date Certificate
Subregistrar Signature o �� I Issued: 3-8-90 Due:
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 Sebastian Cemetery
13ABURIAL ❑ STORAGE Date of Disposition
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person-in-Charge) _�� Q. /a 2-1 -
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)
CEM FIDE
Index : RECORD # NEWCEM Record:386
earc ie - ontents:
City of Sebastian, FL - Cemetery Lots
Last Name REYNOLDS First Name JAMES & AINA
Address 1 P. O. BOX 421H
Address 2
City SEBASTIAN State FL Zip 32978-
Deed At 201 Date )4-20-73 Amount 150
Unit # 1- Block # 35
Lot Number 38 Interred REYNOLDS, ANNA )te Interred 05-22-86
Lot Number 37 Interred Janes E. Reynolds )te Interred 3 -12-90
Lot Number Interred )te Interred
Lot Number Interred )te Interred
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