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Name— / ft' T 1�6' ✓ 2 i Gl l i4 � / IC
Unit /
Block
Lot '
Date of Mark -out _ 1' 610
Date of Burial //0 Time av
Name of Funeral Home S f `` C
Authorized by V, � I�
EPARTMENT OF
FLORIDA ifixi T
A (TYPF)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
Lf I 13Q t3R
1. Name of
First
Middle
Last
Date Month Day Year
Deceased
of
Melvin
Martin
Waters, Jr.
Death Nov. 23 2002
2. Place of Death
City, Town or Location
Name of (If neither, give street address)
County
Hosp. or County
Rd 606 ( Oslo Rd) and west of
Indian River
Vero Beach
Inst. County
Rd 611 (43rd Ave) Vero Bch, F
3. Name of Medical
Address
Phone Number
Certifier Charles A.
Diggs,
A.M.E.
2500
S. 35th Street
Medical Examiner F_jPh
Fort
Pierce, FL
772 -464 -7378
4. Name of Funeral Home /Qi, -fQis�
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
1623 N. Central Avenue
Strunk Funeral Hqine
Sebastian
FL
1228
772 - 589 -1000
5. Check I a. W1 The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. F-1 was contacted on
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 within 72 hours.
C. was contacted on He /she verified that
Medical Examiner, will complete and sign the
m Ical c rt' catio cause of death within 72 hours.
6. Funeral Director/ /MnatWV F.E. No. /Reg. No. Date Signed
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -02 -478
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.
MNo extension of time for filing the death certificate has been requested.
.(rarer^ Date Date Certificate
Subregistrar Signature N, Issued: 11 /23/02 Due: 11/28/02
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL- AT-SEA
A
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.
Method of Disposition:
BURIAL
CREMATION
Signature of Sexton 1
or Person -in- Charge Jr
STORAGE
OTHER (Specify)
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition/ / ^ r;t 7 del e ;;?-
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
CITY OF SEBASTIAN
CITY CLERK'S OFFICE t
otl%olor 1319
13 Cash
UJA
AmountPaid
i 1
001001 208001 Sales Tax �.
001501 322900 Garage Sales W _ p ►� _ _
001501 341920 Copies /Bid Specs. �•VV�
001501 341910 LDC /Code of Ordinances � Q ,�„ • „� ( ` �''� � p 7�Si
001501 362100 Community Center Rent
001501362100 Yacht Club Rent
001501 362150 Non Taxable Rent P r •
001501 343800 Cemetery Lots
601010 343800 Cemetery Lotsj�/f<A.f,
Lot/Niche , Block Unit
001501 369400 Interment Fee
001501369400 Weekend Service�,s
680800 220681 Yacht Club Security Deposit ..�
680800 220682 Community Center Security Deposit s p.
680800 220683 Riverview Park Security Deposit
Total Paid
n als
White — Dept. of Origin • fellow — Finance • Pink - Applicant
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