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LETCHWORTH,
UNIT 1 O.B., Block 26w Lots 21, 22, 23, 2) , 25
36/ 3. , 28, 39, 140
a/k/a Lot 1
III! 1111
Flock 26 Lots 21, 22, 23, 24, 25 Unit, 1 O.F.
36, 37, 3E, 39, 40
a/k/a Lot 1
Letchworth
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1-1- 7 State of Florida,Depart -of Health and Rehabilitative Services,VitaIllistics �` .,
17 APPLICA1Ti)N FOR BURIAL — TRANSIT PERMIT /
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased VIOLA H. SNOWDEN OF December 20, 1996
J4Z ,[(A'p�77-1- ; DEATH
2. Place of Death City, Town or Location Name of (If neither,give street address)
County Hosp. or
Pasco Hudson Inst. Columbia HCA Medical Center
3. Name of Medical I Medical Examiner Address Phone Number
Certifier
Bipin Patel, M.D. --- Physician 813-849-4711
4. Name of Funeral Home/ Address Fla. Lic.No./IiaCg.No. Phone Number(Area Code)
r 1623 North Central Avenue 1228 561-589-1000
Strunk Funeral Home Sebastian, Fla. 32958
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b n Bipin Patel, M.D. was contacted on 12/23/96 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 He 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 state cemetery/ ebastlan Cemetery Removal
Final Disposition: remator y -n m ounty: n from state e
Donation
7. Funeral Director/ ignature F.E. No./_ Ficg.No.• Date Signed
lairect-Dispasex z• S`�
B. BURIAL — TRANSIT PERMIT
Permit No 1228-96-581
Permission is hereby granted to dispose of this body.
❑ 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 filing the death certificate requested.
.iRe Date 12/23/96 Date Certificate
Subregistrar Signature Issued: 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
® BURIAL ❑ STORAGE Date of Disposition Dec.23, 1996
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ) /
or Pares, . C iarAje) vI L':.LC .a . ClCu—t
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 1Replaces Oct 87 edition which may be used)
,Stock Number:574C-000-0326-2)
LC C f ,
I opz/g,
Name //01,41 o LAY
Unit
Block V-6
Lot 3
Date of Mark-out I;Zill ;I/ il‘'Itar
Date of Burial /:24 /c2 3 /?6,- Time /1 6 4.9
Name of Funeral Home 5 ne t4. Ai
Authorized by -r
i!i 0 ), / )79
A Al /-71 a)°
1:-/-17 /