HomeMy WebLinkAbout1-38-05itA rD .1416 617
Unit
Block 3
Name
Lot
Date of Mark -out
Date of Burial
Name of Funeral Home
Authorized by
Paid by CEMETERY Receipt No
List Price 450.00
Net Paid 450.00
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359 Dated 10/17/83
Maximum No. Purial Spaces 2
Monument permitted Flat
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053 :i
Mildred Bryant, and /or Sandra Ellis
13450 99th St.
Fellsmere, Fla. 32948
B.
D.
A. (TYPE)
1. Name of
Deceased
Mildred
First
2. Place of Death
County
Leon Tallahassee
3. Name of Medical
Certifier Dr. Lisa Flannagan
Medical Examiner
5. Check
Appropriate
Box
City, Town or Location
Physician
6. Funeral Director/ Signatu
Direct Disposer Russell M. Newsome
Approval Number:
Medical Examiner,
Methods of Disposition:
BURIAL
CREMATION
II
Signature of Sexton
or Person -in- Charge
DH 326, 8/97 (Obsoletes all previous editions)
(Stock Number 5740 000 -0326 -2)
II
STORAGE
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL TRANSIT PERMIT
Middle Last
Elizabeth Bryant
4. Name of Funeral Home /Direct Disposal Address
Establishment 235 NW Orange Avenue
Beggs Funeral Home Madison Chapel Madison, Florida 32340
61 (850)973 -2258
a. The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
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 cause of Beat yin 72 hou
pH:
medical certification of cause of death within 72 hours.
BURIAL TRANSIT PERMIT
Name of (If neither, give street address)
Hosp. or
Inst. Tallahassee Memorial Healthcare
Address
1899 Eider Court Tallahassee, FL 32308
Fla. Lic. No. /Reg. No
F.E. No. /Reg. No.
F043629
Permission is hereby granted to dispose of this body. Permit No
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 -ath certific- e quested.
Subregistrar Signature
Registrar or Date Date rtificate
Issue f
c. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL- AT SEA
Date
was contacted on/ He /she verified that
Medical Examiner, will complete and sign the
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.
CEMETERY OR CREMATORY e.14 4-
Place of Disposition
Date of Disposition
Date Month Day Year
of
Death March 15, 2011
Phone Number
(850)942 -7473
Phone No. (Area Code)
OTHER (Specify)
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
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
Date Si. ned
Paid by CEMETERY Receipt No 359
Dated 10/17/83
4 50.00 rs
List Price NO.
Maximum No. Purial Spaces 2 Mildred Bryant, and/or Sandra Ei
Net Paid$ 450.00 13450 99th St.
Monument permitted F1 a t Fellsmere, Fla.
32948
Lots 5 6, Block 38, Unit #1 Additional
(Data above this line for City Record only)
Lots 5 6, Block 38, Unit #1 Additional
Deed 539
Mildred Bryant, and /or Sandra Ellis
13450 99th Street
Fellsmere, Florida 32948
Thomas Bryant
Interred 10/18/83, Lot 6