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Date of Burial Time 40
Name of Funeral Home Y R`T . F L JY itA O,/ :
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ii-roj LJ Sate of Florida,datment of Health and Rehabilitative Servic tal Statistics a /6 0 / ( -
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
Willard Elizabeth McCain Clark DEATH July 6,1990
2. Place of Death City, Town or Location Name of (If neither, give street address)
County
Hosp. or
St. Lucie , Fort Pierce Inst. 2607 Lazy Hammock Lane
3. Name of Medical 1 Medical Examiner Address Phone Number
Certifier 1912 Nebraska Ave.
David Fromang, MD xl Physician Fort Pierce, Florida 34950 466-2700
4. Name of Funeral Home/ Address Fla. Lic.No./Reg.No. Phone Number(Area Code)
Direct Disposer P.O. Box 777
Yates Funeral Home, Inc Fort Pierce, Fl. 34954 219 (407) 461-7000
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b ❑
was contacted on within 72
hours after death. 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 of cause of death.
c ❑ was contacted on .He/she verified that
,Medical Examiner,will complete and sign the
medical certification.
6. Place of In state cemetery/ Sebastian Cemetery Removal
Final Disposition: 71 crematory name/c.
y - nt : Indian River
from om state n Donation
7. Funeral Director/ Signature / F.E.No./Reg.No. Date Signed
Direct Disposer Joseph W. Yates, Jr ,/ • 1503
i
B. a RI■L — TRANSIT PERMIT
Permission is hereby Permit No 219-259-90
y granted to dispose of this body.
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit,a"Funeral Director/Direct
Disposer Report"will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filing the death certificat-. .0-sted.
Registrar or �I / Date Date Certificate
Subregistrar Signature . A - ■•4.• 1 V Issued: July 9,1990 Due:
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
Methods of Disposition. Place of Disposition 5.1.
R-BURIAL ❑ STORAGE Date of Disposition 7 to / yo
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton ) i/• /)��
or Person-in-Charge) Q .
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 HRS County Public Health Unit in the County where disposition occurred.
HRS Form 326.Feb 89(Replaces Oct 87 edition which may be used)
(Stock Number:5740-000-0326-2)
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