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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