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.TA'1'1 or FLORIDA .
DBP~aT~TOF. H$AL~H;& RBUABILITATlVE SERVleBS
..XTALSTATI8TIC8
APPL%CATION FOR PB~IT1~ 018INTBR, TRANSPORT & REINTER'
A. Applic~tion is hereby mad~ for a permit to DISINTER, TRANSPORT ,
REINTER the followinq 4uman r~ma1ns; (Tlpe or print)
1.
First
MIddle
Name
of
Deceased CURTIS
Place County
of
Death pINE:tl,M ~
Place of-....-,..," Cemetery
......._~ __J._ _ ...
VL'.;I.\f.:LlItlJ,
Burial a.zAIOfATl!:R ~
I
Place Cemetery
of
Reinterment GMNDVIm C"4!METERY .
Funeral DIrector I Name"'."
Direct Pisposer William R.; Miller
Plaint rr;ln LeWiS Mchn' aI' Hane
Funeral Direotor Name
Direct Disposer
Reinterring . i
Funeral Directorjr-- Siqnature Fla.tlc.NO./Re9.NO.
Direct Disposer ,J~ '. · 3127
Makin~ ~PPlication..(~~l(M~... 7i!.~'I1f)4t
Date' .,
of
, C.. 1 GEER Death.
. 'C1 ty , . 'Town or ,Location
Last
Month D~y
W\Y. 31, 1~62
Age Race
45, WHITE
Add-res a
MALE
Year
2.
Sex
3;
4.
CL~, FLORIDA
Adch:ess
JCJiN~, PJHi$YLVANIA
. Address
9700 'SS'niOOle Blvd~
seminole .Florida i34642
A resa
'Sa.
5b.
6.
Date Slqned
geptEltber S, 1994
........ll~
PERMXT'TQ D~SINTBR,'T~SPURT& REINTER
D. Permission is hereby .granuedto. DISINTBR, TRANSPORT 'REINTER.the
aboYe hum~n remains;
Re9'istr"~ SUb-~tr~ ~
Signatur ~~ . . d. . -"'" .
"...~b_ . ~
Permit No.
1-1994 :
I
Date Issued ~p~8f 1994
Ce~.tery
Agent,
This Permit must be ~;~irendereh by the Puneral Oirector/Di~ect Ois~~~r to
the Cemetery Agent where re1nterment is made. The Cemeter~ Agent (or
Funeral Director/Direct Disposer if there is no sexton) must forward this
Permit within 10 days to the 100a1 County Health Department in the County
where reinterment ooourred.
c. Endorsement. uf Cemete;ry Age.p.t
For
Disint.erment; D~t.e.
ceme~ery
Ag.nt
~ . l
For
Reint.erment;;
Datcl
V"I'~ =-..:...::..:.:~ ~L.
HRS Form 431, oc~ 81 (replaces;prev~ous ed1tlons and HRS:FOrm 757)
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