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Paid by Gener$1 , —�� _ �3 0��� # � e� � �9' �
Receipt No. ~'�"'�•�"•
Dated.. �..�..�..�...... ✓
I.�st R�tce $,.200.00*+a ....... ... ......... .................. Lewta W. & Josephine Ren
......... Micco, �la� shaw
Discount �, .���"�--� Mg�mum No, Butiaj gp�es z
tlet Paid $.200y00*iE .. .. Total area tn sqq�re teet .••••"••••--. .. Lots 21
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A. (Type or Print)
1. Name of First
Deceased
STATE OF FLORIDA
cPARTMENT OF WEALTH & REHABILiTA E SERVICES
VITAL STATISTICS
APPLICATION FOR BURiAL—TRANSIT PERMIT
Josephine
Middle
Last
Renshaw
� v�� � ,� 3 � �,5
�/
DATE Month Day Year
OF
�EATH June 6, 1982
2. Place of Death City, Town or Location Name of (If neither, give st�eet address)
County Hosp. or
Indian River Vero Beach •Inst. Indian River Memorial Hospital
3. Name of Medical �hysician Address
Certif�er Keith Kirby, M.D. � Medical Examiner 777 37th St. Vero Beach Florida
4 uneral H Name Addre
Direct DisPoser Pottinger & Son Funeral Home, S. Indian River Dr. �ebastian Florida 32958
5. �Check a[� The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b �
Box 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.
B.
C
�
�
Direct Disposer
on.
re
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
�� � / .� [ ir .r__... D � / G�
Fla. lic. No./Reg. No.
BURIAL—TRANSIT PERMIT
Date
Permit No. �� '�
Permission is hereby granted to dispose of this body.
� A five day extension of time for fiting the death certificate (exctusive of weekends► has been requested and
granted. If it cannot be filed within this time limit, a"Funeral Director/Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
�
Registrar or
Sub-Registrar Signatu
Date
Issued
AUTHORIZATION for CREMATION, DISSECTtON 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 atter death
is required for all cremations.
Method of Disposition:
� BURIAL � STORAGE
� CREMATION � OTHER (Specify)
Signature of Sexton )
or Person-in-Charae )
CEMETERY OR CREMATORY
Place of Disposition Sebastian Cemetery
Date of Disposition June 10, 1982
.tTza'��-�
This permit m�5t be endorsed by the Sextor(/or p�son-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton)
and returned within 10 days to the local CoSnty Health Depanment in the County where disposition occurred.
HRS Form 326, APR. 81
(replaces previous editions which may be used.)