Sinclair, Helen RBURIAL PERMIT
To: Cemetery Caretaker Permit No.
Clearwater, FL Date: _ q- -Zoo4
Date of Birth: - AD I q I I
Date of Death: fc- (o zoo 4,
Permission is hereby granted for burial of: Helen t?. ??h??atir
PLEASE CHECK ONE (Very Important) URN: FULL?_
Name of deceased: 4cferi ' &vida`ir
Owner of Property: arr prtf 4A ww"', bte, D"-,k • (? -;v;l -6 ode,, Si ,.? IA? r A-J-
Space: Lot: Block: Clearwater Cemetery. j'
Funeral Home: Goss ['?e 4w Funeral Director: Gic- kuge,
Date of Burial: suoe- -;O'-(004 Time: (AM?j
Staking Fee $ 36,'! Paid Date: 7-_d CITY OF CLEARWATER
(lb/dbf/plat/call 6579 & fax to 6551 (Parks & Rec) By: ^?--?
ALSO EMAIL TO: JoEllyn King, Brian Murphree (cell if needed 224-7105)
S:\Records\CEM\BURIAL PERMIT.doc
Clearwater
City of Clearwater, Florida
Official Records and
Legislative Services Department
Phone (727) 562-4090
Fax (727) 562-4086
FAX MESSAGE
TO: JoEllyn King; Brian Murphree
LOCATION: Park and Recreation
FAX NO.: 6551
COMMENTS: See attached Burial Permit information for Helen R.
Sinclair, Block 9, Lot 84, Space 2
FROM: Lois Norman, (727-562-4091)
DATE: 6/29/2004
NUMBER OF PAGES THIS MESSAGE (INCLUDING THIS PAGE): 2
Clearwater
TO:
LOCATION:
FAX NO.:
City of Clearwater, Florida
Official Records and
Legislative Services Department
Phone (727) 562-4090
Fax (727) 562-4086
FAX MESSAGE
Jill
Moss Feaster
562-2007
COMMENTS: See attached map, Block 9, Lot 84, Space 2
FROM: Lois Norman, (727-562-4091)
DATE: 6/29/2004
NUMBER OF PAGES THIS MESSAGE (INCLUDING THIS PAGE): 2
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MOJC s 1320 Main Street, Dunedin, FL 34683
13401 Indian Rocks Road, Largo, FL 33774
FEASTER 693 South Belcher Road, Clearwater, FL 33764
FUNERAL HOMES & 802 North Fort Harrison Avenue, Clearwater, FL 33755
CREMATION SERVICES 2550 Highlands Boulevard North, Palm Harbor, FL 34684
June 30, 2004
Hello, Lois!
Enclosed is the burial permit for Helen Sinclair.
Thank you for your professional and kind support with this matter. It is always so
wonderful when I am allowed to meet such a wonderful person over the phone.
The head stone, by the way, did get fixed. Thanks again for the "heads up" on that one!
(No pun intended)
Sincerely,
Jill Geerlings-Schmidt
727.446.2375 ?? www.yourpartnersinlife.com
Honored Provider
Dignity Memorial-
• 1
FLORIDA DEMUMEN
HEA.LT
A. (TYPE)
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
Helen R. Sinclair Death June 26, 2004
2. Place of Death City, Town or Location Name o (I neither, give street address)
County Hosp. or
Pinellas Clearwater Inst. Oaks of Clearwater
3. Name of Medical Address Phone Number
Certifier Elias Kanaan, MD 414 Jeffords Street (727) 298 - 8496
Medical Examiner ? Physician Clearwater, FL 33756
4. Name of Funeral Home/ Address Fla. Lic. No./Reg. No. Phone No. (Area Code)
Direct Disposer 802 N. Fort Harrison Ave.
Moss-Feaster Funeral Homes Clearwater, Florida 33755 3011 2061 (727) 446 - 2375
5. Check a. The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. [;? Wendy was contacted on 06/29/2004
He/she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that Elias Kanaan MD will complete and sign the medical
certification of cause of death within 72 hours.
o• ? was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
m" I certification of cause of death within 72 hours.
6. Funeral Director/ t e F.E. No./Reg. No. Date Signed
e0ed4N&POW 07-0 -7e L,* June 29, 2004
B. BURIAL - TRANSIT PERMIT Permit No. 2061 - 136
Permission is hereby granted 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.
r-??16rextension of time for filing the death certificate requested.
LL--?Registrar or ` Date Date Certificate
71 -Q
Subregistrar Signature Issued: 06/29/2004 Due: -
C. AUTHORIZATION for CREMATION, DISSECTION or BURIAL- AT - SEA
Approval Number: Date
Medical Examiner, 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
Methods of Disposition: Place of Disposition Clearwater Municipal
yr a Ave., 17 earwa er,
?? BURIAL STORAGE Date of Disposition 06/28/2004
CREMATION OTHER (Specify)
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 the 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
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 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. 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 the signature of applicant Funeral Director, FE License number, or Direct Disposer, Registration Number, and the date the Application
was signed.
Section B.
BURIAL - TRANSIT PERMIT
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 the appropriate box.
The Registrar or Subregistrar who grants 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 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/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 D.
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 method of disposition; fill in the date and place of disposition in space provided.