Merritt, Helen DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle Last
DECEASED DATE Month Day Year
OF(Type or print) Helen M. Merritt DEATH July 23 1978
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF (If not in hospital,give street address)
COUNTY HOSPITAL OR
Pasco New Port Richey INSTITUTION Richey Manor Nursing Home
Attending Physician R] (Name of Medical Certifier) (Address)
Address
Medical Examiners O R. D. Sells M. D. '180i S. Boulevard, New Port Richey, Fl. 33552
Funeral (Name) (Addy ss)
Home Bell Funeral Home 60'1 State RD. 52, Port Richey, Fl. 33568
Check A ❑ A completed certificate of death accompanies this application.
One
B * Dr. B. D. Se11G M. D. was contacted on July 23 19 78
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
7,...
— - 1962 •
July 23, i978
(Signature) (Fla. Lic. No.) (Date Signed)
Funeral G. L. Bell
Director
BURIAL TRANSIT PERMIT Neormit 108k_13
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 A five day extension of time for filing the death certificate has been requested and granted.
Signature o
Registrar e
�` 1 r V Dated
r <
CEMETERY OR CREMATORY
Method of Disposition Date of �/�� �
BURIAL Disposition o
❑ CREMATION c:-_^ � V ��
❑ STORAGE Place of � " c9. -
7❑ OTHER (Specify) Disposition !�7c/7�I
Signature of Sexton
or Person in Charge .° L
This permit must be end rsed by the sexton or per n in charge or 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)