Dorothy Plumbj
N
i3PARTMWrOF State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL — TRANSIT PERMIT
HEALL DATE Month Day Year
(Type or Print) Last OF
A Middle DEATH 10/1/98
First
1. Name of plumb
Deceased
Dorothy Name of (If neither, give street address
City, Town or Location Hosp. or
2. Place of Death Inst. Gulf Coast Medical Center
County Phone Number
Ba Panama City
Medical Examiner Address 785-1332
3. Name of Medical 826 Harrison Ave.
Certifier
Philip J. Faustian, 14D Physician Fla. Lic. No./Reg. No. Phone Number (Area Code
Address
4. Name of Funeral Home/ 2403 Harrison Ave. 2384 gyp -763-4694
Direct Disposer Panama City, FL 32405
Kent–Forest Lawn Funeral Home
❑ on has been completed and s
a The medical certificati
igned. A completed certificate of death accompanies
5, Check this application. 10/2/98 within 7 2
Appr°- � (Paula) was contacted on
priate Phi .1 J. Paustian,
Box b will complete
hours
after death. He/she verified that this death was natural causes, that there was no accident
nor other external cause of death, and that He/she verified that
and sign the medical certification of cause of death. was contacted on
c ® Medical Examiner, will complete and sign the
medical certification. Removal
Donation
In state cemetery/ x
from state
6. Place of 4!4IT
y - name/county: Date Signed
Final Disposition: F.E.15 9 Reg. No. 10/2/98
e 3159
7. Funeral Director/ O
Direct Disposer Permit No. 23845 98
BURIAL — TRANSIT PERM
B.
Permission is her granted to dispose of this body.
t be filed within this extended time limit, a 'Funeral Director/Dire
or filing the death certificate (exclusive no weekends) has been requested and granted as undue ar s
❑x A five day extension of time f death occurred.
would result from filing within theth the al time limit.if
r of theiCountyan
Disposer Report will be ° ifica requested. Date Cextyficftr98
Date 10/1/98 Due: 1U//
❑ No extension of time for fili g the Issued:
Registrar or
Subregistrar Signature
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
C.
Medical Examiner Date
Signature telephone to
or gave authorization by
Medical Examiner, eriod of 48 hours i
Funeral Director/Direct Disposer. Date
The Medical Examiner's approval
must be obtained before disposal by any of the above methods. A waiting p
death is required for all cremations.
CEMETERY OR CREMATORY
D.
Place of Disposition
Methods of Disposition: Date of Disposition
❑ BURIAL ❑STORAGE
❑
❑ CREMATION OTHER (Specify)
Signature of Sexton )
or Person -in -Charge)
he Secton or person -in -charge (or by the Funeral Director/Direct Disposer when there is no S
permit must be endorsed by t Health Department in the County where disposition occurred.
This p s to the local County
and returned within 10 day
Number: DIH 326 10196 Replaces HRS Form
26-2) 326 which may be used)
(Stock