Jeckel, Kim State of Florida • Department of Health and Rehabilitative Services • D n) Health
Burial Permit 4j 1. 0a3
BUR TSIT PERMIT
ce:
Full name of d •d..... S........ = ��
Place of deat�.•< . . ........... h-CLZ-0-&59-1Florida
IV
( i y) ` (County) X 1 • ^ - J
Date of death _ 1 ....:.. Color-/�v/L�i Sex X.1... AgeG_J{14,iX
Method of dis sal. .1.1 l`�
( et r urial, cremation. transportation, stora: etc.) r (Cemetery or Crematory)
Count . .__----.... State /.. ..
fica f de having be n filed as required by t• •411of this St. e, permiss'on is h reby given
IP
to License
(Funer 1 Director or person acting as such)
to dispose of o of old trcceaed as above stated. - 411i) 1
{� I
Date issued_._. l_! (.... Sign ture C9)2.-.t.
(Regist r)
C TERY CR TORY AUTHOO•RrtY S • lFILL • 'J S ACE BELOW
,•l i� -4- / '2 19 4i in. ' .IC/'CQeG�-'z
Body was on.. �•
-(State whe r cremated,buried,stored etc.) Affemetery er Cre story)
Plac .t.. -e--01— � Signature ... ..
J S ton or person in charge)
V S.#640
This permit must be endorsed by the Sexton (or by the Funer. ' rector where there is no sexton) and re-
turned within 10 days to the Registrar of the district in which the burial takes place.