Only, Nathaniel
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-.....I
STATE OF FLORIDA
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES
VI,AL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT
Middle
o The medical certification has been completed and signed. A completed certificate of death accompanies.
~cation. ~0 .
OR ~~ was contacted on ~ff/ within 72
hours after death. He/she verified that this~th was from natural causes, that the e no accident nor
other external cause of death, and that - -- will complete
and sign the medical certification of cause of death,
c 0
medical certification.
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
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6, Funeral Director~
Direct Disposer
Signature .
g: 7; LJ~
Fla, Lic, No./Reg, No,
o:f7;/
Date Signed
1/rjfl
I
Permit No, ""553-
B,
BURIAL-TRANSIT PERMIT
Perm ission is hereby granted to dispose of this body,--
o 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 Count in which death occurred,
o No extension of time or iling the death certific requested,
Registrar or
Subregistrar Signature
Date
Issued:
1- s - 9/ ~~:~ Certificate
C,
HORIZATION for CREMATION, DISSECTION or BURIAL-AT -SEA
Signature
or
Medical Examiner,
, Medical Examiner
Date
, 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
Metho
URIAL
o CREMATION
o STORAGE
o OTHER (Specify)
Place of Disposition
Date of Disposition
~7#/~
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 County Health Department in the County where disposition occurred,
HRS Form 326, Oct 87 (Replaces May 86 edition which may be used)
(Stock Number: 5740-000-0326-2)
Ii
~.
INSTRUCTIONS ON HOW TO CpMPL~TE THE APPLICATION
FOR BURIAL - TRA~SIT fl,ERMIT FORM
Section A.
APPLICATION FOR PERMIT
1. Type or print name of deceased and date of death,
2. Indicate place of death: County; City, Town or Location; hospital or institution (if not in hospital or institution, give street address),
3, Indic~te the name and address of the physician or Medical Examiner who you determine is to provide the medical certification of cause
of death, .
4. Indicate name, address, and telephone number of funeral home or direct disposal establishment.
5,- 'a. Check if a completed death certificate, including the. completed and signed medical certification of cause of death, accompanies
the pink copy of the Application for Burial-Transit Permit to the Local Registrar of the County in which death occurred. (If the
completed certificate cannot be obtained in sufficient time to be filed with the pink copy of the Application, check 5b.)
b. Provide the name of the person contacted in an effort to obtain the name of the physician who is to complete and sign the medical
certification portion of the certificate, and the date he/she was contacted, The person contacted must be either the physician or
a responsible person whom you determine can speak for him/her,
c. Check to indicate if this is a Medical Examiner case, Give the name of the person contacted who verified that the Medical Examiner
will complete and sign the medical certification of cause of death and the date contact was made,
6, Requires signature of applicant, Florida License/Registration number, and date application signed,
Section 8,
BURIAL-TRANSIT PERMIT
Provide permit number, If it is anticipated that' the certificate cannot be filed within five days from the date of death, five additional days (exclusive
of weekends) may be requested and granted by checking the box provided, If this time frame cannot be met, complete and file a copy of
the Funeral Director/Direct Disposer Report with the Local Registrar in the County of death and send a copy to Quality Assurance, Office
of Vital Statistics, If no extension of time is requested, check appropriate box.
The Registrar or Subregistrar who grants the Burial-Transit Permit will sign and date the Permit Application, If it is not convenient for the
Subregistrar to sign, it will be signed by the Local Registrar or his designee. (The signature of the Subregistrar on the Burial-Transit Permit
need n01 be the same as the Subregistrar signature on the death certificate.) Section 382,006, Florida Statutes, requires that a Burial-Transit
Permit be obtained prior to disposition or removal from the State and within five days after death, It shall be mailed or delivered to the Local
Registrar of the County in which death occurred within 24 hours after issuance. NOTE: It is not necessary to wait until the Funeral Director/Direct
Disposer has custody of the actual body to begin the paperwork.)
Section C,
AUTHORIZATION for CREMATION, DISSECTION or BURIAL -AT-SEA
Approval for cremation/dissection or burial-at-sea must be authorized by the Medical Examiner, Space for his approval signature and date
are provided, In addition, space is provided for the name of the person obtaining telephone approval from Medical Examiner and the date
such approval was obtained,
(NOTE: DO NOT HOLD UP FILING THE PINK COPY WHILE AWAITING MEDICAL EXAMINER APPROVAL.)
Section 0,
CEMETERY OR CREMATORY
Requires: Signature of Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton); appropriate box checked
to indicate method of disposition; date of disposition; place of disposition,