Macintyre, Eileen 414
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle Last DATE Month Day Year
DECESED
(Type orprint) EILEEN (AKA ELLA) MacINTYRE DOF
EATH June 5, 1978
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF (If not in hospital,give street address)
COUNTY
Broward MargateSPITAL NOSTIIT TIONR Margate General Hospital
Attending Physician 0 (Name of Medical Certifier) (Address)
Medical Examiners Q Shashi B. Gore, M.D. , 5301 S.W. 31 Ave., Ft. Lauderdale, Florida 33312
Funeral (Name) (Address)
Home R. Jay Kraeer, 1 North State Road 7, Margate, Florida 33063
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
n , 19 •
a = 10 8 June 7, 1978
(Signature) (Fla. Lic. No.) (Date Signed)
Fune al John 0. Watson, Jr.
Director
Age 41 BURIAL TRANSIT PERMIT Permit 821-439
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
RegistrarA...e&le,,,
•, 0 "/�, e° _ Issued June 1 8
7, 97
J.) R Brewer, Sub. Reg.
CEMETERY OR CREMATORY
Method of Disposition Date of
❑ BURIAL Disposition �//' Q-7:7 O'
❑ CREMATION
❑ STORAGE Place of (%
i] OTHER (Specify) Dispositio
Removal �� 7,,F,,,,,,._4,.....„\Signature of Sexton
or Person in Charge
.
This permit must be end ed by the sexton or person in charge tor by the funeral director when there is no sexton)
and returned within 10 days to the local county health department.
HRS Form 326 (1/77)