Potter Jr, Arden DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
414.
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
NAME OF First Middle Last DATE Month Day Year
(Type( nt) ARDEN W . POTTER , JR . DEATH Feb . 8 , 1979
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF J( frnetgn h�spit aitet et address)
coUNTHi 11 sborough Tampa NOSTIT TIAL C1R
ON Vi Medical Center
Attending Physician n (Name of Medical Certifier) (Address)
Medical Examiners ❑ Robert T . Peterson , 1300J N . 30th St. , Tampa , Fla .
Funeral (Name) (Address)
Home B . Marion Reed Co . , 258 Plant Ave . , Tampa , Fla . 33606
Check A 0 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 ! 1523 Feb . 9 , 1979
Director
BURIAL TRANSIT PERMIT Permit 56-022
No
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 �Xt�w Date
Registrar \ �\./''('`j Issued Feb . 9 , 1979
CEMETERY OR CREMATORY
Method of Disposition Date of Feb . 10 , 1979
❑ BURIAL Disposition
❑ CREMATION
Pine View Cemetery
❑ STORAGE Place of Queensbury , New York
�] OTHER(Specify) Disposition
Removal
Signature of Sexton ; �f
or Person in Charge ,
This permit must be endorsed 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)
t ForAVS-67 (rev. 11!65)
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
FUNERAL DIRECTOR or UNDERTAKER'S REQUEST TO DISINTER BODY
In completing this form, please typewrite, hand-print or write legibly all entries in permanent black or blue black
ink. Signatures should be legible. This is a permanent record. When data cannot be obtained, write "UNKNOWN"
in applicable spaces.
I hereby request permission to disinter the dead body of: -
Name of g., ceas'd 1 Mote Age(yra.)
i. �.: - Et Female
``,• -,
Place Death (indicate whether city, village or town) Date of L` ath Cause of Death
1 et rvi 13 ei— i /41.-... d' 71 (iG-?ye e i ;r/
c{metery noII.4 interred Location(city,town or county) Is body to be transported by common carrier?
IJ It _.. G i Csr.L t ' t L ( . IL a , 1- �' f- --,7 ,4. ''J A 0 Yea (i^7- No
State fully the final disposition to be made of body.
v c j r► t'1 •
Narire o place me; etery r final disposition �/ Date.of flna clispq°Jt!
, 3PC .4Ae_(-i IA nit, it� ��� �� ���/
Firm a flea. Po. Address
i7e. 1 4t 1e're'l! (,!'l'f'0' ,
,Slgnatuie f Funeral Dir odor Do, _" ~
j Rt Reg No. Date /L/7 y -,
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
•
•
1. See Section 13.1 (formerly Chapter XIII, subdivision 4) of the Sanitary Code, relating to the transportation of dead bodies
by common carriers, as printed on the back of the Transit Label.
2. The data required concerning the decedent may be obtained from the local register or cemetery record.
INSTRUCTIONS TO LOCAL REGISTRAR:
1. For bodies to be transported by common carrier, fill out Transit Permit.
2. For bodies not to be transported by common carrier, fill out ordinary Official Burial (or Removal) Permit.
3. In each case write the word "DISINTERMENT" on the Permit.
4. This form should be filed and carefully preserved in your office.