Clark, Robert ix
State of Florida, Department of Health, Bureau of Vital Statistics
Fp.�EH BURIAL TRANSIT PERMIT
HFA,1TH DATE PRINTED:January 13.2017 TRACKING NUMBER: 2017006419
1. DECEDENT INFORMATION
Name of Deceased Date of Death
ROBERT R CLARK January 11,2017
Place of Death-County City,Town or Location Name of fealty,or street address if not a facility
POLK LAKELAND LAKELAND REGIONAL MEDICAL CTR
Name and Address of Funeral Home/Direct Disposal Establishment Fla.Lic.No./Reg.No. Phone Number
LOYLESS FUNERAL HOME F040834 P040834 (813)996-6E10
6310 LAND 0 LAKES BLVD
LAND 0 LAKES,FLORIDA,34630
Funeral Director/Direct Disposer Fla.Uc.No./Reg.No.
JOHN B.WALSH F042723
2• BURIAL- TRANSIT PERMIT
The Florida Department of Health,Bureau of Vital Statistics
hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes.
Permit Number: 2017-F040834-6031
41,a4y0,4004_,_ Date Issued: January 12,2017
State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL-AT-SEA,or HOSPITAL DISPOSITION
Authorization given by Medical Examiner District 10 Approval Number:
4. CEMETERY OR CREMATORY
Place of Disposition: PINE VIEW CREMATORY VV(
Method of Disposition: REMOVAL FROM STATE Date of Disposition: 7
EDRS maintains all statutorily required information regarding the death record and related
burial transit permit,therefore,returning the permit to the county health department Is no
longer required.
If the Place of Final Disposition wishes to retain the copy of the permit to - the may do so.
DM 326E,is/ta
64V-1.011,Florida Administrative Code
ri-peke ,7