Cohen, Gustave DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle Last DATE Month Day Year
DECEASED
(Type orrprint) Gustat Cohen D AFTHFebruary 21, 1979
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF (If not in hospital,give street address)
COUNTY HOSPITAL OR
Dade MIAMI INSTITUTION N.W. 37th AVE & 18 S_2.
Attending Physician ❑ (Name of Medical Certifier) (Address)
Medical Examiners k CHARLES WETLI M.D. 1050 N.W. 19th ST. MIAMI, FLORIDA
Funeral (Name) (Address)
Home Gordon Funeral Home , 710 S.W. 12 Ave. , Miami, Fl 33130
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
(Signature) (Fla. Lic. No.) (Date Signed)
Funeral
Directo G J Z. /O S . February 21, 1979
Permit
BURIAL TRANSIT PERMIT No.
No. 041-1319
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 February 21, 1979
Registrar Issued
EMETERY OR CREMATORY
Method of Disposition Date of ) / r/
❑ BURIAL Disposition
❑ CREMATION
❑ STORAGE Place of Sharray Tefila Cemetery
OTHER(Specify) Disposition Glen Falls, N.Y.
Remova/leic14
Signature of Sexton
or Person in Charge
This permit must be en orsed by the sexton or person 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)