Clark, Ray L
STATE OF FLORIDA
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR PERMIT TO DISINTER, TRANSPORT & REINTER
A. Application is hereby made for a permit to DISINTER, TRANSPORT &
REINTER the following human remains: (Type or Print)
1. Name First Middle Last Date Month Day Year
of of
Deceased RAY L. CLARK Death October 17. 1968
2. Place County City, Town or Location Age Race Sex
of
Death Pinellas St. Petersburg 38 White Male
3. Place of Cemetery Address
Original Clearwater Cemetery Clearwater, Florida
Burial
4. Place Cemetery Address
of Woodlawn Cemetery LaFollette, Tennessee
Reinterment
Sa. Funeral Director/ Name Address
Direct Disposer Thomas G. Thompson 499 N. Indian Rocks Road
Disinterring Hubbell Funeral Home Belleair Bluffs s FL 34640
Sb. Funeral Director/ Name Terry Smith Address
Direct Disposer Cross Funeral Home 301 E. Central Avenue
Reinterring LaFollette, TN 37766
6. Funeral Director/ Signature Fla.Lic.No./Reg.No. Date Signed
Direct Disposer ~ ,.--7
Making Application....?'"'~~...47~~~ 1411 10, .25-95
PERMIT TO DISINTER, TRANSPORT & REINTER
B. Permission is hereby granted to DISINTER, TRANSPORT & REINTER the
above human remains:
Permit No.
(2 ..~;)-O
Registra
Signature
Date Issued
C. Endorsement of Cemetery Agent
For
Disinterment: Date:
Cemetery
Agent
For
Reinterment:
Date:
Cemetery
Agent:
This Permit must be surrendered by the Funeral Director/Direct Disposer to
the Cemetery Agent where reinterment is made. The Cemetery Agent (or
Funeral Director/Direct Disposer if there is no sexton) must forward this
Permit within 10 days to the local County Health Department in the County
where reinterment occurred.
HRS Form' 431, OC~ ~l (replaces previous editions and HRS Form 757)
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Dat~ !/~ / i\
Date of BinhA/A
Date of Death lfA-
Name of deceased
Permission is hereby granted for burial
Owner of property
Space ,-3 Lot U Bitt: Clearwater Cem~y
'/.'loeral Home !ll./iJ!)f..l-( /i;L~M (/ Ir:.~;-- Direc'o& . (~ 7// (J
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Staking Fee $ 30- ~:i~ /1-~-.r;S- AL. ~J~ 1___
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