Smith, Curtis DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle Last DATE Month Day Year
DECEASED Curtis OF
(Type or print) Cu R Smith DEATH March 10, 1977
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF (If not in hospital,give street address)
COUNTY HOSPITAL OR
Broward Hollywood INSTITUTION Memorial Hospital
Attending Physician ® (Name of Medical Certifier) (Address)
Medical Examiners ❑ Stanley L. Simpson DO 5951 W Hallandale Bch Blvd Hollywood, Fla
Funeral (Name) (Address)
Home Boyd's Funeral Homes 6100 Hollywood Blvd Hollywood, Florida 33024
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 ❑ The attending physician was unavailable or this death comes within the Medical Examiners
jurisdiction. The body was released to me by
on , 19
.A, , / 1597 March 11 , 1977
(Signature) (Fla. Lic. No.) (Date Signed)
Funeral r 7 ,
Director
BURIAL TRANSIT PERMIT Permit
No. 16 — 105
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 grantea.
Signature of Date
Registrar Issued March 11 , 1977
CEMETERY OR CREMATORY
Method of Disposition Date of
❑ BURIAL Disposition March 14, 1977
❑ CREMATION
0 STORAGE Place of
® OTHER (Specify) Removal Disposition
Signature of Sexton •
or Person in Charge y ,This permit must be endorsed bjr 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.