Davis, Douglas W
FLORIDA DEPARTMENT OF
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
A.
1. Name of
Deceased
(TYPE)
First
Middle
Last
Date
of
Death
(If neither, give street address)
Month
Day
Year
Douglas
w.
Davis
June 6, 2001
Usha Agarwal, MD
Medical Examiner
4, Name of Funeral Home/Direct Disposal
Establishment
Thomas B. Dobies
5. Check a.
Appropriate
Box
New Port Riche
Address
5347 Main Street,
New Port Riche
Name of
Hosp. or
Inst.
Phone Number
2. Place of Death
County
Pasco
3. Name of Medical
Certifier
City, Town or Location
hysician
Address
Suite #102
FL 34652
Fla. Lic. No.lReg. No.
6616 Congress St
Funeral Horn New Port Richey FL 34653 2116 (727) 841-7555
D The medical certification has been completed and signed. A completed certificate of death accompanies this
application.
b. [!]
Dr. Aqarwal's Office (Amanda).. wascontactedon .... .. 0n/07/nl
He7sfie verrnea1hat ffiis ireatnwas fronfmifliraT causes, fhaftherewas no accident nor other external cause of death,
and that Usha Aqarwal , MD will complete and sign the medical
certification of cause of death within 72 hours.
c. D
was contacted on
He/she verified that
, Medical Examiner, will complete and sign the
6. Funeral Director/
Direct Disposer
medical certification of cause of death within 72 hours.
Signature F.E. No.lReg. No.
:h/
Date Signed
B.
BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 2116-132
D 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.
[]No extension of time for filing the
Re!lietrar sr
Subregistrar Signature
Date
Issued:
06/07/01
Date Certificate
06/11/01
Due:
C.
AUTHORIZATION 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 Cemp-tp-ry
D.
GBURIAL
DSTORAGE
Date of Disposition
DCREMATION
Signature of Sexton
or Person-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) and returned
within 10 days to the local County Health Department in the county where disposition occurred.
DH 326. 8/97 (Obsoletes all previous editions)
(Stoel< Number: 5740-000-0326-2)
Distribution: White: Cemetery or Crematory
Yellow: Funeral Director or Direct Disposer
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 offuneral 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, check5b.)
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.
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 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 the method of disposition; fill in the date and place of disposition in space provided