HomeMy WebLinkAbout1-09-40Name
Block
Lot ___ -�fo
Date of
Date ofBurial llme
Name of Funeral nome____-_-�'
Authorized
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FLORIDA DEPARTMENT OF
HEAL�T
A (TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
U r M L yo
1. Name of First Middle
Last
Date
Month Day Year
Deceased
of
Kathleen Raen
Waters
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 Beach, 1
3. Name of Medical
Certifier C arles A. Diggs, A.M.E.
Address
2500
S. 35th
Street
Phone Number
Fort
Pierce,
FL
772 -464 -7378
Medical Examiner Physician
4. Name of Funeral Home /D4@sWW*peeal
Address
Fla. Lic. No. /Reg. No.
Phone No. (Area Code)
Establishment
1623 N. Central Avenue
Strunk Funeral Hollpe
Sebastian,
FL
1228
772- 589 -1000
5. Check a. t+ u The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. 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
medic certifi atio , of c ,e' of death within 72 hours.
6. Funeral Director/ Sig t e F.E. No. /Reg. No. Date Signed
Q4eet- Bispeser 1862 11/25/02
B. � BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 1228 -02 -479
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.
No extension of time for filing the death certificate has been requested.
Date Date Certificate
Subregistrar Signature Ok C,,.V"9 L Issued: 11 /23/02 Due: 11/28/02
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 Sebastian Cemetery
BURIAL STORAGE Date of Disposition %` off- 7 r' C1-o
CREMATION 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
DH 326, 6/97 (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 1.
RECEIPT
Cash
Date r o2e 01 eck #��
Amount Paid (�i �p d�
001001 208001 Safes Tax NA
001501 322900 Garage Sales U _ a
001501 341920 Copies /Bid Specs.
001501 341910 LDC /Code of Ordinances
001501 362100 Community Center Rent
001501362100 Yacht Club Rent
001501 362150 Non Taxable Rent L07- •
001501 343800 Cemetery Lots
601010 343800 Cemetery Lots S f A&& d" 9.11L&,`, % / �p' 7► /V a �•
Lot/Niche , Block Unit
001501 369400 Interment Fee
001501369400 Weekend Service ,40),fr(��
680800 220681 Yacht Club Security Deposit
680800 220682 Community Center Security Deposit s�a�✓�
680800 220683 /Riverview Park Security Deposit
n /� O e
als Total Paid
White - Dept. of Origin • Yellow - Finance • Pink - Applicant