Mason, Walter HEAFzo ��nn.•A o State of Florida, Department of Health,Vital Statistics
LL APPLICATION FOR BURIAL-TRANSIT PERMIT
A. (TYPE)
1. Name of First Middle Last Date Month Day Year
Deceased
of
WALTER JOHN MASON Death May 04 2011
2. Place,of Death City,Town or Location Name of (If neither,give street address)
County Hosp.or
Orange Orlando Inst. Florida Hospital Orlando
3. Name of Medical Address Phone'Number
Certifier Rajeev Sood, M.D. 10000 West Colonial Drive, Ocoee, Florida 34761 (407)961-4698
I I Medical Examiner t X l Physician
4. Name of Funeral Home/Direct'Disposal Address Fla.Lic.No./Reg.No. Phone No.(Area Code)
Estdblishment Loomis Funeral Home 420 West Main Street
• A000ka. Florida 32712 F040605 (407)880-1007
5. Check a 0 The medical certification has been completed and signed.A completed certificate of death accompanies,this
Appropriate application.
Box
b. ® Raieev Sood. M.D. was contacted on 5/6/2011
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. Raieev Sood will complete and sign the medical
certification of cause of death within 72 hours.
c. ❑ was contacted on .He/she verified that
J ,Medical Examiner,will complete and sign the
medical certification o -rise of dea h within 72 hours.
6. Funeral Director/ Si F.E.No./Reg.No. Date Signed
Direct Disposer
F045506 May 6. 2011
B. BURIAL-TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. F40605-2011-533
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.
❑ No extension of time for fill he death 'ficate has been requested.
Registrar or r Date Date Certificate
Subregistrar Signature At& Issued: May 6. 2011 Due: May 16. 2011
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL-AT-SEA
t-W
Approval Number: Date �- 1
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•. FOR FUNERAL DIRECTOR/DIRECT DISPOSER USE ONLY
1.Date Burial-Transit Permit(pink copy)was filed with.Local Registrar: May 6.2011
2.Date Temporary Certificate was filed with Local Registrar:
3.Date Permanent Certificate was filed with Local Registrar:
4.Follow-up efforts&activities(Note parties&dates contacted):
5.Name and place of disposition: Metro Crematory Inc. Ocoee. Florida
6.Funeral Director/Direct Disposer Report Filed: Yes No x Date Filed:
FUNERAL DIRECTOR/DIRECT DISPOSER COPY
DH 326,8/97(Obsoletes all previous editions)
(Stock Number:5740-000-0326-2)