Petrie, Edmund W 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 OF
Ec'trnund Wart Petrie DEATH February 5, 1990
2. Place of Death City,Town or Location Name of (If neither,give street address)
County Hosp.or
Orange Orlando Inst. Florida Hospital
3. Name of Medical Medical Examiner Address Phone Number
Certifier
Joel D. Greenberg, MD Physician 615 E. PrinCetoin Avenue, Orlando, FL 894-4474
4. Name of Funeral Home/ Address Fla.Lic. No./Reg.No. Phone Number(Area Code)
Direct Disposer 600 E. Wilkinson Street
Garden Chapel Hone for Funeralsj Orlando, Florida 32803 766 407/898-7881
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box Dr. GreehI e l s Office 2/6/90
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 Dr. Greerberg 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 Fine ViEW Crematory In state emeter Queensbury, New York Removal
Final Disposition: cremato -n e/ ounty: X from state Donation
7. Funeral Director/ Si n tur F.E.No./Reg.No. Date Signed
Direct Disposer Lawrence J. Bla,rl{w 49/1562 February 6, 1990
B. BURIAL — TRANSIT PERMIT 766-5198
Permit No.
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.
❑ No extension of time for filing the death certificate requested.
Registrar or Date 2/6/90 Date CertifVT5/90
Subregistrar Signature r Issued: Due:
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
Signature Medical Examiner Date
or
Medical Examiner, Kevin Smith at 0.C.M.E.@4:OOP16ave authorization by telephone to Lawrence J. Blackwood
Funeral Director/Direct Disposer. Date February 6, 1990
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
❑ BURIAL ❑ STORAGE Date of Disposition
, CREMATION ❑ OTHER ( ecify)
Signature of Sexton )
or Person-in-Charge)
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)