Bulman, Alice 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
ALICE K. BULMAN DEATH March 11, 1987
2. Place of Death City, Town or Location Name of (If neither, give street address)
County
Hosp. or
Pasco New Port Richey Inst. Riverside Hospital
3. Name of Medical ® Physician Address
Certifier Melvyn G. Drew, M.D. ❑Medical Examiner 490 W. Embassy Blvd.-Port Richey, FL 33568
4. Funeral Home/ Name Address
Direct Disposer Wellwood Funeral Home 16931 U.S. 19-Hutson, Florida 33567
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b D Dr. Drew was contacted on 3/11/87. He/she verified that
this death was from natural causes, that there was no accident nor other external cause of death, and that
he 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.,EBey_N.Q. Date Signed
Di•rcct Diapescr ,/ �• z9/2-- March 11, 1987
B. BURIAL-TRANSIT PERMIT
Permit No. WFH1223-0990
Permission is hereby granted to dispose of this body.
0 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.
Pi,._:_..... ,. Jet-
/46: / H'. i �• Date
March 11, 1987
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
Method of Disposition: Place of Disposition Pine View Cemetery
❑x BURIAL ❑ STORAGE Date of Disposition
❑ CREMATION ❑ OTH (Specify)
Signature of Sexton ) /
or Person-in-Charge ) n(Lc r -- t�"--t.-9./2 , ' ,t1.
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.)