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SLATE OF FLORIDA
UFPARTMFNT OF HEALIH AND REHABILITATIVE SERVICES
�-� C? l /a • VITAL STATISTICS
APPLICATION FOR BURIAL -TRAMT PERMIT
NAME OF rst `Middle / Last/ DATE pay Yeor
(Type oED �L f S �Y/CWILL f� OA(Type or or print) l�.!!�� �Tx G H LC
PLACE OF DEATH CIT ,TOWN, LOCATION NAME OF (If not in hospital give street address)
CO Y HOSPITAL o
A / �/ �+, f/. INSTITUTION l%a ll'i'`�'!/
Attending Physician V (Name of Medic ertifier) (Add rpss)
Medical Examiners ❑ C��g2,�,S � `pis
Funeral amIt � Le�� 12-
'! ( dress)
Home i.. ��... _ 11. _ _ . /.,.� i. /,W A �.
Check A ❑ A completed certificate of death accompanies this application.
One
B W Dr.._. wascontocted on -DG • /� -177
He has assured 6fie that this death was from natural causes and that he will complete and T.
the medical certification of cause of death.
C ❑ The attending physician was unavailable or this death comes within the Medical Examiners
jurisdiction. The body was released to me by __._ _._
on 19 - .
(Sign (Fla. lic. No.) (Date Signed)
Funeral
Director lZ
BURIAL TRANSIT PERMIT Permit
No.- IJ 0 ^S7 9
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For
cremation a waiting period of 48 hours after death must be observed and the Medical Examiner's approval must
also be obtained.
❑ A five day extension of time for filing the death certificate has been requested and granted.
Signature of
Registrar awleta
Method of Disposition
❑ BURIAL
❑ CREMATION
❑ STORAGE
❑ OTHER (Specify)
Signature af'- 9exfvn+
,pr Person in Charge
CEMETERY OR CREMAT
Date of
Disposition
Place of
Disposition
Date
Issued
This permit must be endorsed by the sexton or person in charge jor by the funeral director when there is no sexton)
and returned within 10 days to the local county health department.
HFIS Form 326 (1/77)
0
(re Parks sister's old deed)
221 10 -27 -71
Paid by General Receipt No . ............. .... Dated ..............................
List Price $ ................. . Maximum No. Burial spaces ......... .
Discount $ ................... Total area in square feet ................
Deed ;i'173
L
Charles L. Ailliams
P.O.Box 674 (Rt.1,Pryor's Camp)
Aahasso, Fla.
*. Lots 15 and 15
Net Paid $ ..... 2.0 0...0 ...... Monument permitted .....................
Block 36
(Data above this line for City Record only) Unit ,f 2
Block 36
Lots 15, 16
Williams, Oharles L. Deed #173
Williams, Mrs. Charles L.
P. o. Box 674 n's (Y.
Wabasso, Fla.
Unit 2
Jennie Williams interred 10129180
lot 16
WILLIAMS, Charles L.
WILLIAMS, Mrs. Charles Lo
C.
UNIT 2, Block 36, Lots 15, 16
Charles L. Williams interred Dec. 12, 1979.
Jennie Williams interred 10129180
lot 16
-P e r / --10/ 1 Y