Stark, Herbert 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
HERBERT M. STARK DEATH DEC. 7, 1994
2. Place of Death City,Town or Location Name of (If neither, give street address)
County Hosp. or THE PALACE AT KENDALL NURSING
DADE MT MT
Inst. AND REHABILITATION CENTER
3. Name of Medical Medical Examiner Address Phone Number
Certifier
CARMEN ROMERO, M.D. x Physician 4302 ALTON ROAD # 530, MIAMI BEACH, FL. 531-6600
4. Name of Funeral Home/ Address Fla.Lic. No./Reg.No. Phone Number(Area Code)
Direct Disposer 11220 N. KENDALL DRIVE
VAN ORSDEL KENDALL CHAPEL MIAMI, FLORIDA 33176 1609 (305) 279-6644
5. Check a ❑ The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate
Box b cn DR. ROMERO'S OFFICE was contacted on 12/8/94 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 SHE OR ASSOCIATE 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/ Removal
Final Disposition: crematory -name/c nty: x from state Donation
7. Funeral Director/ �-_ajgilatur F.E.No./Reg.No. Date Signed
Wifeet
- � 3045 DEC. 8, 1994
B. A TRANSIT PERMIT 1609-388
Permission is h eby granted to dispose of this body. Permit No.
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 r uested.
ate Date Certificate
Subregistrar Signat re Issued: DR' 8,1gq[l Due:
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 PINE VIEW CEMETERY
Methods of Disposition: Place of Disposition QUEENSBURY, NEW YORK
❑ BURIAL ❑ STORAGE Date of Disposition �3 ` /
CREMATION cify) REM0 L FROM STATE
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)