Loading...
Miller, John STATE OF FLORIDA DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES VITAL STATISTICS APPLICATION FOR BURIAL—TRANSIT PERMIT A. (Type or Print) 1. Name of First Middle Last DATE Month Day Year Deceased OF JOHN LEROY WILLER DEATH June 5, 1984 2. Place of Death City, Town or Location Nz.me of (If neither, give street address) County Hosp. or Lake Leesburg Inst. 1201 Lee St. Lot 132 3. Name of Medical ® Physician Address Certifier G. H. Binneveld, M.D. ❑Medical Examiner 1028 W. Magnolia St., Leesburg, Fla. 4. Funeral Home/ Name Address Direct Disposer Beyers Funeral Home, 1123 W. Main St. Leesburg, Fla. 32748 5. Check a ® The medical certification has been completed and signed. A completed certificate of death accompanies Appro- this application. priate b ❑ was contacted on . He/she verified that Box this death was from natural causes, that there was no accident nor other external cause of death, and that will complete and sign the medical certification of cause of death. c was contacted on . He/she verified that , Medical Examiner, will complete and sign the medical certification. 6. Funeral Director/ Signature Fla. Lic. No./Reg. No. Date Signed Direct Disposer �,,.. --,r,✓ 2284 June 6, 1984 B. BURIAL—TRANSIT PERMIT 173-25g1 Permit No. Permission is hereby granted to dispose of this body. A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed with the Local Registrar of the County in which death occurred. Registrar or Date June 6, 1984 Sub-Registrar Signature Issued C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA Signature , Medical Examiner Date or Medical Examiner, , gave authorization by telephone to Funeral Director/Direct Disposer. Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is required for all cremations. D. CEMETERY OR CREMATORY ;, -e_ry e Method of Disposition: Place of Disposition YJ C V� �1/t) Ct/v11(`1ry BURIAL El STORAGE Date of Disposition � — f- 8 V— D 1 CREMATION 0 OTHER (Specify) Signature of Sexton ) or Person-in-Charge ) This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned within 10 days to the local County Health Department in the County where disposition occurred. HRS Form 326, APR. 81 (replaces previous editions which may be used.) INSTRUCTIONS ON HOW TO COMPLETE THE APPLICATION FOR BURIAL—TRANSIT PERMIT FORM Section A. APPLICATION FOR PERMIT 1. Type or print name of deceased and date of death. 2. Indicate place of death: County; City, Town or Location;hospital or institution (if not in hospital or institution, give street address). 3. Indicate the name and address of the physician-or Medical Examiner who you determine is to provide the medical certification of cause of death. (Name of a group practice, hospital staff, District Medical Examiner's office, will suffice.) 4. Indicate name and address qf funeral home or direct disposal establishment. • 5. a. Check if a completed death certificate, including the completed and signed medical certification of cause of death, accompanies • the pink copy of the Application for Burial—Transit Permit to the Local Registrar of the County in which death occurred. (If the completed certificate cannot be obtained in sufficient time to be filed with the pink copy of the Application, check 5b.) b. Provide the name of the person contacted in an effort to obtain the name of the physician who is to complete and sign the medi- cal certification portion of the certificate, and the date he/she was contacted. The person contacted must be either the physician or a responsible person whom you determine can speak for him/her. The name of a group practice, staff physician or a similar description may be substituted for the name of a specific physician. c. Check to indicate if this is a Medical Examiner case. Give the name of the person contacted who verified that the Medical Exam- iner will complete and sign the medical certification of cause of death and the date contact was made. 6. Requires signature of applicant, Florida License/Registration number, and date application signed. Section B. BURIAL—TRANSIT PERMIT Provide permit number. If it is anticipated that the certificate cannot be filed within three (3) days from the date of death, five (5) additional days (exclusive of weekends) may be requested and granted by checking the box provided. If this time frame cannot be met, complete and file a copy of the Funeral Director/Direct Disposer Report with the Local Registrar in the County of death and send a copy to Quality Con- trol, Office of Vital Statistics. The 'Regist`rar or Sub-Registrar who grants the Burial—Transit Permit will sign and date the Permit Application. If it is not convenient for the Sub-Registrar to sign, it will be signed by the Local Registrar or his designee. (The signature of the Sub-Registrar on the Burial—Transit Per- mit need not be the same as the Sub-Registrar signature on the death certificate.) Section 382.061, Florida Statutes, requires that a Burial— Transit Permit be obtained prior to disposition or removal from the State and within 72 hours after death. It shall be mailed or delivered to the County Registrar of the County in which death occurred within 24 hours after issuance. NOTE: It is not necessary to wait until the Funeral Director/Direct Disposer has custody of the actual body to begin the paperwork.) Section C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA Approval for cremation/dissection or burial-at-sea must be authorized by the Medical Examiner. Space for his approval signature and date are provided. In addition, space is provided for the name of the person obtaining telephone approval from Medical Examiner and the date such approval was obtained. (NOTE: DO NOT HOLD UP FILING THE PINK COPY WHILE AWAITING MEDICAL EXAMINER APPROVAL} Section D. CEMETERY OR CREMATORY Requires: Signature of Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton); appropriate box checked to indicate method of disposition;date of disposition; place of disposition.