Campbell, Thomas State of Florida • Department of Health and Rehabilitative Services • Division of Health
; Burial Permit No c'-'52/cR.7
BURIAL- RANSIT PERMIT
,
k Full name of deceased..1-4/721.4.-- ,
! Place of death Florida
(City) ?./..(County)
„
Date of death.....1...,,,-- eet.t.....1:...3 19 7/2e Color.. Sex C71 Age\5-7
Method of disposal... ilealet2 ‹-e e",-r 4t1 12 ,
•
' (712gther burial, cremation, transportation, storage, etc.) ( emetery or Cre tory)
, Count red elea -e State L-2...e.1-1/-1
/ e..e _Akic_e ..tifigat of de th ving been filed as required by the laws o this State, permission is hereby given
to ./ , License
r
(Funeral Director or p son acting as such)
to dispose oety:ki. of said deceased as above stated.
Signature.&424.1 _.../(LeXteizeT
(Registrar)
CEMETERY/OR CREMATORY AUTHORITY,SHALL_FILL OUT, ' r
SPACE BELOW
/
( // 19/ in, I Body was - ' ' 1 't j ( ._...on -- /-/.4- ,
' 1 " ' ' -- I `
(State whether creme, 'fed, buried,,/stored.etc.) (C,meteryt.„9,r Cre t.)ory)
_-- ----9
Place......1...4.:,!..,,, __.a • I , / 7, , t • "f ..4 , Signature V'
. , ( -, ,e'., /, , — - -
—- Sexton or person in charge)
V.S.#640 .../
This permit must be endorsed by the Sexton (or by the Funeral Direor where there is no sexton) and re-
turned within 10 days to the Registrar of the district in which the burial takes place.