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Home My WebLink About1-12-15 I 3 C/A4. ,, /://"7 I / 0 3 r O r d r Cr , r - wv w iJ` Z V Lp i1� t. o 7- � : • Cj '•O l r x t C, ' 1 tft � 11 1t " • o �— V co.? 1+ i D e (. G.r •P W dC 0 O .r.. F Y t� , 6' Z y r .... ‘:'1' \j-\ 0.- AN( I 0*.• n z il Cy i 3 —�Tr\ 1 7zi Z CI CP. G -- . -� .- m H — I — cow NJ' ' ' K O 70 - N vl o /� CV Ti 4 .__ — 3> A STATE OF FLORIDA 1- 'i iliPARTMENT OF HEALTH & REHABILITAW SERVICES VITAL STATISTICS /'I 1� APPLICATION FOR BURIAL—TRANSIT PERMIT lA A. (Type or Print) 1. Name of First Middle Last DATE Month Day Year Deceased OF BEULAH RUTH LIGHTSEY DEATH July 16.,1982 2. Place of Death City, Town or Location Name of (If neither, give street address) County Hosp. or Duval Jacksonville Inst. Methodist Hospital 3. Name of Medical 6 Physician Address Certifier James W. Bond DJviedical Examiner Methodist Hospital, Jax. Fla .32209 4. Funeral Home/ " Name Address Direct Disposer Hgrdage & Sons 517 Park St. , Jacksonville , Fla. 32204 5. Check a E] The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate b Dr. Bond was contacted on 7-17'82He/she verified that Box this death wasfrom 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. Funeral D;� . // Sig f ture Fla. Lic. No./Reg. No. Date Signed Direct Di ., r • 4. �� 2370 July 17,1982 B. BURIAL—TRANSIT PERMIT 734-350 B Permit No. Permission is hereby granted to dispose of this body. E] A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed with the Local Registrar of the County in which death occurred. Registrar or f Date July 17, 1982 Sub-Registrar Signature V ""�. Issued 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 . Method of Disposition: Place of DispositionSeba.-tan Ceinetvuj © BURIAL D STORAGE Date of Disposition Jai/ 16, 1982 ❑ CREMATION 0 OTHER (Specify) Signaturein Sexton ) �,��-c�C � �.� or Person-in-Charge 1 '�-�-� 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. HRS Form 326, APR. 81 (replaces previous editions which may be used.)