Simmes, Richard 4
FL'IRIDA DEPARTMENT OF State-of Florida, Department of Health, Vital Statistics
I EAL l APPLICATION FOR BURIAL-TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased of
Richard Simmes Death 02 16 2011
2. Place of Death City,Town or Location Name of (If neither,give street address)
County Hosp.or 5612 SW 58th Place
Marion Ocala Inst.
3. Name of Medical Address Phone Number
Certifier Thomas J Fuller MD 9505 SW 110th Street
In Medical Examiner Physician Ocala, Florida 34481 352-291-5100
4. Name of Funeral Home/Direct Disposal I Address Fla.Lic.No./Reg. No. Phone No.(Area Code)
Establishment 6241 SW State Road 200
Roberts Funeral Home Ocala, Florida 34476 F041248 352-854-2266
5. Check a. El The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. ® Dr. Fuller' s office was contacted on 02/17/2011 .
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 within 72 hours.
c. El was contacted on He/she verified that
, Medical Examiner,will complete and sign the
/ edi certificy'.n of cause of death within 72 hours.
6. Funeral Director/ 6` :),--r re F.E. ./Re Date Signed
Direct Disposer / �'` ' Ara.-"'-'"'' / %7 ��d 02/17/2011
B. BURIAL-TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. F041248-2011-299 -
®A five(5)day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within
72 hours.
D No extension of time for filing t e death certificate has been requested.
Registrar or '' Date Date Certificate
Subregistrar Signature Issued: 02//16/2011 Due: 02/2 6/2011
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA
Approval Number: Date
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
®BURIAL 0 STORAGE Date of Disposition 2/21/2 011
CREMATION OTHER(Specify)
Signature of Sexton
orPerson-in-Charge } Michael Genier/Superintendent ��ti� Q
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.
Distribution: White: Cemetery or Crematory
DH 326,8/97(Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740-000-0326-2) Pink: Local Registrar