Dark, Richard DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle Last DATE Month Day Year
DECEASED OF
(Type or print) RICHARD DAVID DARK DEATH July 24, 1979
PLACE OF DEATH CITY, TOWN,OR LOCATION NAME OF (If not in hospital,give street address)
COUNTY HOSPITAL OR
Broward Margate INSTITUTION TION Margate Bld. & U.S.#441
Attending Physician ❑ (Name of Medical Certifier) (Address)
Medical Examiners ) Abdullah Fatteh, M.D., 5301 S.W. 31st Ave., Ft. Laud., Fla.
Funeral (Name) (Address)
Home R,Jay Kraeer, F.H., #1 N. State Rd. #7, Margate, Fla., 33063
Check A Et A completed certificate of death accompanies this application.
One
B El 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
19
�` 181 July 25, 1979
/ (Signature) (Fla. Lic. No.) (Date Signed)
Funeral (v,
Director Frank J. Lawless
Age 53 BURIAL TRANSIT PERMIT Permit
No. 821-816
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 A Iste
R9�Registrar Issued July 25, 1979
CEMETERY OR CREMATORY
Method of Disposition Date of❑ BURIAL Disposition July 25, 1979
❑ CREMATION
❑ STORAGE Place of
Pine View Cemetery. Queensbury, New York
OTHER (Specify) Removal Disposition
Signature of Sexton
or Person in ChargeiO4
This permit must be endorsed 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)