Lacios, Athena
IHlRJl)A IJEPAKTMENT OF
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
HEALT
A (TYPE)
1. Name of
Deceased
First Middle
Clearwater
Last Date Month Day Year
of
Lacios Death July 13, 2005
Name of (If neither, give street address)
Hosp or
Insl. 1121 S. Duncan Avenue
2, Place of Death
County
Pinellas
3, Name of Medical
Certifier Paul DiMarco
Athena
City, Town or Location
Medical Examiner X
4, Name of Funeral Home/Direct Disposal
Establishment Rhodes Funeral
Directors Inc.
5, Check a, 0
Appropriate
Box
Physician
Address
Address
417 Corbett St.
Clearwater, FL 33756
Phone Number
(727)
441-4581
MD
830 N. Belcher Rd.
Clearwater, FL 33765
The medical certification has been completed and signed,
application.
Fla, Lic, No.lReg, No, Phone No (Area Code)
(727)
446-2222
2633
A completed certificate of death accompanies this
b, Ii]
Corisa was contacted on July 13, 2005
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Dr. DiMarco 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
B,
e of death within 72 hours,
FE No.lReg, No,
rlE" (l
Date Signed
7/13/05
6, Funeral Director/
Direct :Jisposer
BURIAL - TRANSIT PERMIT
Permission is hereby grante to dispose of this body,
~ A 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,
ONo extension of time for filing the death certificate has been requested,
Registrar or
Subregistrar Signature
Permit No, 2174-191
Date
Issued:
7/13/05
Date Certificate
7/25/05
Dlje:
C,
AUTHORIZA TION for CREMATION, DISSECTION, or BURIAL-AT -SEA
Approval Number:
Date
Medical Examiner, , gave authorization by telephone to
Funeral DirectorlDirect 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,
Method of Disposition:
CEMETERY OR CREMATORY
Place of Disposition Clearwater Cemetery
D,
ijBURIAL
DSTORAGE
Date of Disposition
DCREMATION
Signature of Sexton
or Per,>o:>n-in-Charge
DOTHER (Specify)
}
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton,' c;r.:' ~:;turned
within 10 days to the local County Health Department in the county where disposition occurred,
DH 326, 8/97 (Obsoletes all previous editions)
(Stock Number: 5740-000-0326-2)
Distribution' While: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
Pink: Local Registrar
R<<]<'oIG,"l'U
INSTRUCTIONS ON HOW TO COMPlETE THE APPLICATION
FOR BURIAL-TRANSIT PERMIT FORM
APPLICATION FOR PERMIT
Section A.
1, Type 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, Indicate the name, address, and telephone number of the Medical Examiner or physician who is to provide the medical certification of cause of
death,
4, Indicate name, address, telephone number, and license 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 the 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 who can speak for him/her.
c, Che.ck_to il1~ic;atEllft,!is i~a_ M~dlc:al Exalllil1erc_as~-,-~Give_th~~~f!~~p~rsol! ~ontacted ,^"hov~rified that the Medic:_a-,-!,:xaminer will
complete and sign the medical certification of cause of death and the date contact was made,. -- - --
6, Requires the signature of applicant Funeral Director, FE License number, or Direct Disposer, Registration Number,and the date the Application
was signed,
BURIAL-TRANSIT PERMIT
Section B,
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 no extension of time is requested, check appropriate box,
The Registrar or Subregistrar who issues the Burial-Transit Permit will sign and date the Permit Application and assign the permit number. Section
382,006, Florida Statutes, requires that a Burial-Transit Permit be obtained prior to disposition or removal from the State and within five (5) 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 DirectorlDirect Disposer has custody of the actual body to begin the paperwork,
AUTHORIZATION FOR CREMATION, DISSECTION, or BURIAL-AT -SEA
Section C,
Approval for cremation, dissection, or burial-at-sea must be authorized by the Medical Examiner. Space for his/her approval number and date are
provided, In addition, space is provided for the name of the person obtaining telephone approval from the Medical Examiner and the date such
approval was obtained,
(NOTE: DO NOT HOLD UP FILING THE PINK COpy WHILE AWAITING MEDICAL EXAMINER APPROVAL)
CEMETERY OR CREMATORY
Section 0,
Required: Signature of Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton,); check the appropriate box to
indicate the method of disposition; fill in the date and place of disposition in space provided