Novitsky, Max STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle
DECEASED MAXast DATE Month
(Type or X NOVITSK�.r OF Day Year
print) KY DEATH JAN 5, 1978
PLACE OF DEATH CITY, TOWN,OR LOCATION
NAME OF
COUNTY BROWARD HOSPITAL OR (If not in hospital,give street address)
MARGATE INSTITUTION MARGATE GENERAL HOSPITAL
Attending Physician (Name of Medical Certifier)
Medical Examiners 0 DR. ZEL BURNSTELN 201 NORTH UNIVERSITY DRIVE, PLANTATION,FLORIDA
Funeral (Name)
)
Home BOULEVARD CHAPELS 100 SOUTH DIXI HIGHWAY HALLANDALE,FLORIDAdress 33009
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 0 The attending physician was unavailable or this death comes within the Medical Examiners
jurisdiction. The body was released to me by
.t � , 19
1818 JANUARY 5, 1978
(Signature) (Fla. Lic. No.) (Date Signed)
Funeral RICHARD D. MATHER
Director
BURIAL TRANSIT PERMIT Permit 1045-195
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 granted.
Signature of Date
Registrar (�� Issued JANUARY 5, 1978
CEMETERY OR CREMATORY
Method of Disposition Date of JANUREiY 6, 1978
❑ BURIAL Disposition
❑ CREMATION
❑ STORAGE Place of SHAAREY TEFILA CEMETERY
ja OTHER (Specify) REMOVAL Disposition GLENS FALLS, NEW YURK
Signature of Sexton
or Person in Charge 670/et-
This permit must be endorsed by the sexton or person in charge tor by the funeral director when there is no sexton)
• returned within 10 days to the local county health department.