Selleck, Florence FLORIDA STATE BOARD OF HEALTE
i Burial Permit No 0?••••57
BURIAL-TRANSIT PERMIT
,
1 Full name of deceased 10. a La.212-iii_ C--,-11() I L ti f.d A
! Place of death J.L.t.ria..) 1441C4a/&11. Florida
(citY) 1 .cCounty) 84
Date of death 410,13,tiztAii. P-4 191.0 colon/AM= r, , ge 1712
• Method of disposal.. amitati C1-0.4, FUrik UULLA.1
i (Whether burial, cremation, transportation, storage, etc.) (Cemetery or Crematory)
County .A101r1 O4- state na.,,,cteA JA21
; A certifLille of 4/attar, been filed as required by the lAws of this State, permission is hereby give'
?••
• to ,UQ.,11:' II , License No /6 09
I (Funeral Dt tor or person acting as such)
p to dispose op,a dy said deceased as above stated. Q
• Date issued.. et /7 1 y 7.4 signature 0,12.4.-4,044-1-1214,1-0, —
(Registrar)
ICEMETERY,L&JR CREMATORY AUTHORITY S FILL OUT SPACE,I,BELO
Body was.,2941" --e..,--- I on '- i c;-- 197' iir __./ 4
--- .1,..
tate whethe emated, burled, etc.kl: 4emete -or )
,-- ----(S \("),
Place /4*1-f--'''n i‘- 6-1-f--4-.tt'f' (-kr , -1/Signature......:
V.S.#640 (--- /7.- (Sexton orperson in charge)
• This permit must be endorsed by the Sexton (or by thtlattneral--Director where there is no sexton) and re
turned within 10 days to the Registrar of the district in which the burial takes place.
READ CAREFULLY
REGISTRAR: This burial-transit permit may be issued only in accordance with Section 382.06 Florida Statutes.
FUNERAL DIRECTORS: The burial-transit permit is required for any manner of disposition of a dead body in-
cluding interment, storage, cremation, and transportation. A permit is required for each stillbirth, before disposal
of the body.
Before shipment by common carrier, the body must be embalmed; or if that is not practicable must be enclosed
in a tightly sealed casket or outer case.
SEXTON: It is unlawful for any sexton, or other person in charge of a burial place, to permit burial or other
disposition of a dead body before a burial-transit permit is deposited with him. (The sexton may accept the
permit of any state or of the District of Columbia, as authorization for burial.)
All permits must be endorsed,recorded in your sexton's register, and forwarded within ten days to the registrar
for your district.
TRANSPORTATION AGENT: Be sure that a properly completed burial-transit permit accompanies each body. Do
not accept a body for shipment if fluid or offensive odors are escaping from the case. Fill out the attached
coupon and mail it to the Florida State Board of Health, Jacksonville 1, Florida, within 24 hours after ship-
ment of body.
PENALTY for violations is up to $500 for each offense.