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STATE OF FLORIDA L
iikARTMENT OF HEALTH & REHABILITAOSERVICES / 2
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
LORITA CAIN FLYNT DEATH December 7, 1985
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Saint Lucie Fort Pierce Inst. Lawnwood Regional Medical Center
3. Name of Medical
[A Physician Address
Certifier Leonard Walker, M. D. O Medical Examiner 6015 Silver Oak Drive, Ft. Pierce, Fl 33450
4. Funeral Home/ Name Address
Direct Disposer Yates Funeral Home, Box 777, Ft. Pierce, Florida 33454
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b was contacted on . He/she verified that
Box 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 of
cause of death.
c 0 was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
medical certification.
6. Funeral Director/ Signature Fla. Lic. No./Reg. No. Date Signed
Direct Disposer
Joseph W. Yates, Jr. 1344 December 9, 1985
•
B. BU IAL—TRANSIT PERMIT ,�qq
Permit No..21 -
Permission is hereby granted to dispose of this body.
0 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 c / Date
Sub-Registrar Signatur / /�, �
/ -�. 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 Disposition EEAA-STTAN CEMETERY
la BURIAL STORAGE Date of Disposition DECEMBER 10, 1985
El CREMATION OTHER (Spec' /�
Signature of Sexton
or Person-in-Charge (24
DEBORAH C. KRAGES, CITY CLERK
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.)