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J 1 N I r [ 't I L V t4 I V A
DEPARTMENT OF HEALTH AND REHAUILITAI IVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL - TRANSIT PERMIT
F first Middle Last DATE
Minnie Grace Boyd U AFTH
Month Day~ Year
May 31 1979
P -ACE OF DEATH CITY TOWN, OR LOCATION NAME OF (if not in hospital, give street address)
C7l1NTY HOSPITAL OR Home
Dade Mi ami INSTITUTION Jackson Manor Nurs•
Attending Physiciari�7, - - -J - - - - - - -- � - -- (Name of Medical Certifier) (Address)
s e.hrul Exnmmers I I Edward H. Cottler 1674 Meridian Ave. Miami Beach, Fla.
F,meral ^ (Narne) (Address)
Home Van Orsdel Bird Road Funeral Chapel 9300 SW 40 St. Miami,Fla. 33165
Check A A completed certificate of death accompanies this application.
One
B ❑ Dr. was contacted on ___ ;19
He has assured me that this death was from natural causes and that he will complete and sign 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 .
sa
Funeral
(Signature) (Fla. Lie. No.) (Date Signori) Director Of L .0 6-1 -79
BURIAL TRANSIT PERMIT Permit
No
Nermission is hereby 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. T
LJ A five day extension of time for filing the death certificate has been requested and granted
Signature / Date
Registrar Issued
�--
CEMETERY OR CREMATORY
Method of Disposition
Date of
June 2,
1979
a BURIAL
Disposition
�i CREMATION
STORAGE
- Place of
Sebastian
Cemetery, Sebastian, Fla.
OTHER(Specify)
Disposition
_ - -_
Signature of Sexton
or Person in Charge
This permit must be endorsed by the sexton or person in charge (or by the funeral director when there is no sexton) and returned
within 10 days to the local county health department.
HRS Form 326 (1/77)
�. d