Suckman, Carl VI
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle Last DATE Month Day Year
DECEASE I OF
(Type or print) Carl Suckman DEATH February 10, 1977
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF (If not in hospital,give street address)
COUNTY HOSPITAL OR
Pinellas South Pasadena INSTITUTION paw of Pasadena Hospital
Attending Physician ❑ (Name of Medical Certifier) (Address)
Medical Examiners a John J. Shinner, M➢-260 Ulmerton Road West, Largo, Florida
Funeral (Name) (Address)
Home R. Lee Williams Funeral Home-3530 49th Street North, St. Petersburg, Florida
Check A ❑ A completed certificate of death accompanies this application.
One
B ❑ Dr. was contacted on _—__ , 19
He has assured me that this death was from natural causes and that he will complete and sign
the medical certification of cause of death.
C la The attending physician was unavailable or this death comes within the Medical Examiners
jurisdiction. The body was released to me by the M.E. office][
on Feb., 10 , 19 77.
(Signature) (Fla. Lic. No.) (Date Signed)
Funera
Director (d �L_--�� February 11, 1977
BURIAL TRANSIT PERMIT Peormit 364-60
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For
cremation a waiting period of 48 hours after death must be observed and the Medical Examiner's approval must
also be obtained.
[ A five day extension of time for filing the death certificate has been requested and grantee.
cizzSignature of Date
Registrar Issued February 11, 1977
CEMETERY OR CREMATORY
Method of Disposition Date of //f jam/ 77
(y.. BURIAL Disposition 7
❑ CREMATION
❑ STORAGE Place of
❑ OTHER (Specify) Disposition (S' 11 LZ Yrcr Imo✓ ' a.• `/ems+-+f T�•c
7-(4/•1 )` e C4 14 J r y/ AI Y
Signature of Sexton
or Person in Charge
This permit must be endorsed by the sexton or person in charge for by the funeral director when there is no sexton)
and returned within 10 days to the local county health department.