Mary Elizabeth TrumbleFLORIDA DEPARTMENT OF
SALT
A /TVPPI
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
W
1. Name of First
Middle Last
Date
Month Day Year
Deceased
of
ary
E'liZACIII
"humble
Death
Novamber 2' , 200
2. Place of Death City, Town or Location
Name of
(If neither, give street address)
County
Hosp. or
orpurrac Winkr Giuderit
Inst.
Golders Ponds Communities AssWd Livia
3. Name of Medical
Address
Phone Number
Certifier Don Huswetl-Chaltkow
It 1401 West Colonial
Drive
Medical Examiner ysician
Ocoee FL 34761
407-877-2111
4. Name of Funeral Home/Direct Disposal jAddress
Fla. Lic. No./Reg, No.
Phone No. (Area Code)
Establishment
428 Fa Planif St.
Baldwin-FakcWd Funeral ti
Wince Glardm FL 32757
1-l(JO01:307
407.656-2233
5. Check a. [__j The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b,X-was contacted on
He/she verifthat th' eath was/m natural causes, th t ere was naccident nor other external cause of death,
and that Q 1 will complete and sign the medical
certificatio on f cause of death within 72 hours.
c. El was contacted on He/she verified that
, Medical Examiner, will complete and sign the
me ical certification of cause f death within 72 hours.
6. Funeral Director/ V4a ure F.E. No./Reg. DateSig
Direct Disposer d
B. BURIAL - TRANSIT PERMIT W27
ermission is hereby granted to dispose of this body. Permit No.
A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
een 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 I' g e death certificate s been requested.
Registrar or Date DateCertifica e
Subregistrar Signature Issued: u Due:O LQ
C. �bUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
A
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.
Method of Disposition:
BURIAL
11 CREMATION
Signature of Sexton 1
or Person -in -Charge J}
STORAGE
FISTHER (Specify)
CEMETERY OR CREMATORY
Place of Disposition
Em
Date of Disposition November 25. 2002
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.
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