Beswick, Mary OF
^"R""`IN" State of Florida, Department of Health,Vital Statistics
Il �� APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
MARY REOUX BESWICK DEATH JUNE 18, 1997
2. Place of Death City,Town or Location Name of (If neither, give street address)
County Hosp.or
PALM BEACH WEST PALM BEACH Inst. ST. MARY'S HOSPITAL
3. Name of Medical I Medical Examiner Address Phone Number
Certifier
DR. ALEXANDER MIRANDA XX1 Physician 1411 NO. FLAGLER DR. ,W.PALM BEACH 833-2477
4. Name of Funeral Home/ Address Fla.Lic.No./Reg.No. Phone Number(Area Code)
Direct Disposer 5608 BROADWAY
NORTHWOOD FUNERAL HOME WEST PALM BEACH, FL 333 561-844-4311
5. Check a IN The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b ❑ was contacted on 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 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. Place of � In state cemetery/ MC
I
Final Disposition: I crematory- e/county: f�l from state n Donation
7. Funeral Director/ nat F.E. No./Reg.No. Date Signed
Direct Disposer 3`170 JUNE 18, 1997
B. BURIAL — TRANSIT PERMIT
Permit No. 333-.6692
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 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.
12 No extension of time for filin e death certificate requested.
Registrar or Date Date Certificate
Subregistrar Signatu Issued:JUNE 18, 1997 Due: JUNE 25, 1997
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 Pine View Cemetery
BURIAL ❑ STORAGE Date of Disposition 4-,2 3 -?7
o CREMATION ® OTHER (Specify) Removal-Burial
Signature of Sexton ) _ 1
or Person-in-Charge) _
This permit must be endorsed by the Secton 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.
DH 326,10/96(Replaces HRS Form 326 which may be used)
(Stock Number: 5740-000-0326-2)