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Buchanan, Lois • Date: Cemetery Call Work Sheet Funeral Horne / Monument Company: "oss Cea5+- ? Contact Name: t . Tel. #:IG ?? Fax #: Reason for call: n /4- It f /01, (?jl (c ?? ? ?' Que. ?"glutd, E bu&ma-?A Deceased Name: 1?6<-? Buwarar) Date of Birth: I q 13Date of Death Block Lot _L% Space 4 • 1 '?1(t? ?,?l?Q Owner of Plot: owhm Interment: (One full burial and one urn, or two urns per space) Full Burial Urn Space $30.00 Staking Fee - received on: l / Zq / a- -D (0 /, Og' Date of Burial: tot) ID Time: 4 :VV amffi-m-) Disinterment: The following authorization should be obtained prior to disinterment: 1.) A disinterment permit and burial/cremation transit permit 2.) Written authorization from the individual(s) who currently own the burial rights for the plot; and 3.) Written authorization from the individual(s) who would be permitted to authorize burial 0 Monument Being Placed: (No Fee for Staking ofMonument)?> ?1J • o L U b 11 z % 0 va ? z o H a w z r o ? z y n 00 ,? y0 a b n b W N ?-+ n -71 -TI -rl r r r ? r r r ?' r y b c c ? tv a ? ? r a r z z a ? d z r l7 m r r ? 3 tz- n e4 w O O O d N Nl? O y x Oo A A cr ?D (.A A N \ Z, U U d b ? O O 7 y z y 3 CrJ z H a? c 0 0 A ?o r' 0 N A? y O 0 H N 0 N 0 F?+ 0 4 0 2 0 1 Certificate of Cremation THIS CERTIFIES that the remains of Lois Hummel Buchanan who died January 19, 2010 was cremated on the date indicated below, JAN 2~ ''0111 and these are the cremated remains of said deceased. Permit No. 2010-41198-035 I Southeastern Crematories FLORIDA DEPARTMENT OF HEALT A. State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT 1. Name of First Middle Last Date Month Day Year Deceased of T .,;o T-T„mmPl Rnrhanan Death Januarv 19. 2010 2. Place of Death City, Town or Location County Pinellas Ozona Name of Hosp. or Inst. (If neither, give street address) 301 Shore Drive 3. Name of Medical Address Phone Number Certifier Jose Torres MD Medical Examiner Physician 2323 Curlew Rd., Palm Harbor 34683 727 786-8825 4. Name of Funeral Home/Direct Disposal Address Fla. Lic. No./Reg. No. Phone No. (Area Code) Establishment 13401 Indian Rocks Road Moss Feaster Funeral Homes Largo, FL 33774 F041198 727 562-2080 5. Check a. Fl The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b. Jo was contacted on 1/20/2010 He/she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Dr. Torres will complete and sign the medical certification of cause of death within 72 hours. c. 0 was contacted on He/she verified that , Medical Examiner, will complete and sign the medical certifi ation of cause of death within 72 hours. 6. Funeral Director/ Sign ire F.E. No./Reg. N//o??. Date Signed Direct Disposer 0? el "I A4 $?Q l0 1/22/2010 B. BURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body- Permit No. 2010-41198-035 rXA 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. F1 No extension of time for filing the death certificate has been requested. Registrar or Date Date Certificate Subregistrar Signature zIssued: 1/22/2010 Dye: 1/29/2010 o, C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL-AT-SEA Approval Number:1C? p Date ©r?o Medical Examiner, ?l 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 Southeastern Crematory FIBURIAL STORAGE Date of Disposition JAN 27 201Ca 13CREMATION OTHER pecify) Signature of Sexton 1 or Person-in-Charge J} This permit must be endorsed b th 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 Count ealth 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 Ranra #41 NpR