Vanderlann, Adrianna FLORIDA nEPwxr►,��rr(o'F State of Florida, Department of Health,Vital Statistics
HEAL APPLICATION APPLICATION FOR BURIAL — TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
ADRIANNA VANDERLANN DEATH MARCH 1,, 1999
2. Place of Death City, Town or Location Name of (if neither, give street address)
County Hosp. or
LEE FORT MYERS BEACH Inst. 941 SENECA TRAIL
3. Name of Medical _x Medical Examiner Address Phone Number
Certifier 70 DANLEY DRIVE, FORT MYERS, FL 33907 941-277-5020
REBECCA HAMILTON, MD. Physician
4. Name of Funeral Home/ Address Fla.Lic. No./Reg.No. Phone Number(Area Code)
Direct Disposer FORT MYERS 1589 COLONIAL BOULEVARD
MEMORIAL GARDENS FUNERAL HOME FORT MYERS,, FL 33907 1448 941-936-0555
5. Check a 0 The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b M THE MEDICAL EXAMINERS OFFICE was contacted on 3-3-99 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 DR. HAMILTON 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 PINE VIEW In state cemetery/ QUEENSBURY, NEW YORK Removal
Final Disposition: cEmETERy n crematory -name/county: X from state I I Donation
7. Funer I DirectQr/ ature r- F.E. No./Reg. No. Date Signed
Fa L1LI 1 1 3-3-99
B. BURIAL — TRANSIT PERMIT G-99-88
Permit No.
Permission is hereby granted to dispose of this body.
Cid 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.
❑ No extension of time for fili he death certificat ue ted.
Registrar or Date Date Certificate
Subreqistrar Signature Issued: 3-3-99 Due: 3-12-99
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 0 STORAGE Date of Disposition 3/5/9 9
0 CREMATION HER (Specify)
Signature of Sexton ) �,f
or Person-in-Charge) 1L.4AZ/
/-1�
)i1,12,-,,a,
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)