Perkins, Charles State of Florida • Department of Health and Rehabilitative Services • Division of/ ..1
yHeeaalth
L-
Burial Permit No /
BURI —TRANSIT/APERM IT, -
Full name of dece sed `� GX ' l�
Place of death .._. ..- got.ets-..e4.,- Florida
I
(City it/
t
Date of death ... _. 19 7 Color v�/ Sex Age v
Method of disposal �.. tl
(W ethe b i , cremation, transportation, storage, (Cemetery`or.Cre�atory)
County State � 1 (C
rtificate of dea have en filed as required by the laws of this tate, (l� fission is hereby given
to �i� i/" (�`� License No �T G2...
(Funeral Director or person act as such)
to dispose of bo of said deceased as above stated. •,
Date issued ZI• 30.-/ 9 7 ' Signature e2 �k ha
(Registrar)
�EMETERX OR CREMATORY AUTHORITY SHALL Our SPACE BELOW
Body was. ""t'u.-X-o`- on 's441 7 19A� in. {.7.k tom- r 'c'Lecx i° �(
�,(State whether cremated, buried stored, etc.) ( etery of "'t
Place-_/...0 Signa.c -C' . Signature ' • 1�J.-t. t
.--), 7 (Sexton or person in charge)
V.S.$646 L -
This perm must be endorsed by the Sexton (or by the Fune <1 Directo where there is no sexton) and re-
turned within 10 days to the Registrar of the district in which th- • i. kes place.