Sinnott, John FRS State of Florida,Department of Health and Rehabilitative Services, Vital Statistics
APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased JOHN E E. S INNOTT DEATH MAY 14, 1992
2. Place of Death City,Town or Location Name of (If neither,give street address)
County Hosp. or
PALM BEACH WEST PALM BEACH Inst.C.W.GERSTENBERG HOSPICE CENTER
3. Name of Medical I Medical Examiner Address Phone Number
Certifier 5300 EAST AVE.
LAWRENCE A. TEPPER, D.O. Physician WEST PALM BEACH, FL 33407 848-5423
4. Name of Funeral Home/ Address P. 0, BOX 1816 Fla.Lic.No./Reg.No. Phone Number(Area Code)
Direct Disposer 425B W. DANIA BEACH BLVD.
NIXON FUNERAL SERVICE, INC. DANIA, FL 33004 FH 0001590 305-922-5102
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b [ 3 DR. TEPPER was contacted on 5/14/92 within 72
hours after death. 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 c rtification.
6. Place of In state ce ry/ Removal
Final Disposition: �` crematory 'rpe/c ty: ,t 1 from state 1 1 Donation
7. Funeral Director/ Signatu F.E. No./Reg.No. Date Signed
Direct Disposer . „ 1/11 FE 3 211 MAY 14, 1992
C
B. i7 BURIAL — TRA SIT PERMIT 15 9 0-16 7
Permit No.
Permission is hereby granted dispose of this body.
U A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit.If the certificate cannot be filed within this extended time limit,a"Funeral Director/Direct
Disposer Report" will be filed with the Local Registrar of the County in which death occurred.
El No extension of time for filing the death certifica e requested.
Registrar or ` Date Date Certificate
Subregistrar Signature mcli):1
� B-REG. Issued:MAY 14, 19 9 2 Due:
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
Methods of Disposition: Place of Disposition %`- f r ' - '-f 7
2/BURIAL ❑ STORAGE Date of Disposition �' % 7-/ '
❑ CREMATION ❑ T.I IC (Specify)
Signature of Sexton ) / r
or Person-in-Charge) ,^- - .` - )1, 2 �
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 HRS County Public Health Unit in the County where disposition occurred.
HRS Form 326,Feb 89(Replaces Oct 87 edition which may be used)
(Stock Number:5740-000-0326-2)