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OTD, Mrs. H. B.
'��UNIT I O.Re, Flock 1, Lots 21, 22, 239 �4, 25
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a/k/a Lot 2
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674 ...........
1
STATE OF FLORTOA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS I'�, ✓j ,
APPLICATION FOR BURIAL- TRA.rSIT PERMIT
NAME OF
First
Middle Lost
DATE Month Day Year
DypeAorprint) St.
Clyde
Boyd
DEATH August 14, 1979
PLACE OF DEATH
CITY, TOWN, OR LOCATION
NAME OF (If not in hospital, give street address)
COUNTY
Dade
North Miami
HOSPITAL OR
INSTITUTION North Miami Convalescent
Attending Physician
(Name of Medical Certifier)
(Address)
Medical Examiners ❑
Robert R. Fionte, DO, 777 N.W. 155th
Lane, North Miami Beach, Florida
Funeral
(Name)
(Address)
Home Van Orsdel Bird Road Funeral Chapel, 9300 S.W. 40th Street, Miami, Florida
Check A Lx� 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 _____
(Signature)
_,19
854
(Fla. Li,.. No.)
Funeral
Director
WJ;RIAL TRANSIT PERM11
August 15, 1979
(Date Signed)
Pere it 159 - 417
No.— — —
Home
Permission is hereby granted to dispose of this body by burial, transportaton out of state, storage or cremation_ For crema #+en-a- -
Waiting period of 48 hours after death must be observed and the Medical Examiner's approval must also be obtained.
Signature of
Re4istrar
❑ A five day extension of time for filing the death certificate has been requested and granted.
CEMETERY OR CREMATORY
August 15, 1979
Method of Disposition Date of
M( BURIAL Disposition
❑ CREMATION
❑ STORAGE Place of Sebastian Cemetery
❑ OTHER(Specify) Disposition
Sebastian, Florida
Signature !
4w-Person in
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)