Howard M. Therkelsen1W
STATE OF FLORIDA
DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES.
VITAL STATISTICS
APPLICATION FOR BURIAL—TRANSIT PERMIT
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased OF
HOWL M. THERKELSEN DEATH J=Q 160 1986
2. Place of Death City, Town or Location Name of (If neither, give street address)
County Hosp. or
Hroward Ft. Lauderdale Inst. Las 01as C=nmity Hospital
3. Name of Medical Ek Physician Address
Certifier Vincent Pianelli, M.D. ❑Medical Examiner 303 S.E. 17th St., Ft. Lauderdale, Fla.
4. Funeral Home/ Name Address
Direct Disposer Kalis Funeral Home, 2505 N. Dixie Hwy., Ft. Lauderdaler Fla. 33305
5. Check a ® The medical certification has been completed and signed. A completed certificate of death accompanies
Appro- this application.
priate b ❑ was contacted on He/she verified that
Box this death was from natural causes, that there was no accident nor other external cause of death, and that
will complete and sign the medical certification of
cause of death.
6. Funeral Director/
M
C ❑ was contacted on. He/she verified that
Medical Examiner, will complete and sign the
medical certification.
Signature Fla. Lic. No./Reg. No. Date Signed
Direct Disposer
J -I (u IrZ #1032 .Tune 20, 1986
BURIAL. -TRANSIT PERMIT 78-2375
Permit No.
Permission is hereby granted to dispose of this body.
® A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and.
granted. If it cannot be filed within this time limit, a "Funeral Director/Direct Disposer Report" will be filed
with the Local Registrar of the County in which death occurred.
Registrar or
Sub -Registrar Signatu
Sub—Reg. Date jure 20, 1986
Issued
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA,
Signature , Medical Examiner Date
or
Medical Examiner, Ronald K. Wright, M.D. gave authorization by telephone to �� Kalis,
Kalis Funeral Rom Funeral Director/Direct Disposer. Date 6-19-1986
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.
_31. FOR FUNERAL DIRECTOR/DIRECT DISPOSER USE ONLY
1, Date Burial -Transit Permit (pink copy) was filed with Local Registrar:
2. Date Temporary Certificate was filed with Local Registrar:
3. Date complete Certificate was filed with Local Registrar:
1. Follow -Up Efforts & Activities (Note parties & dates contacted)
;. Funeral Director/Direct Disposer Report filed: Yes No . Date Filed:
FUNERAL DIRECTOR/DIRECT DISPOSER COPY
IRS Form 326, APR. 81
replaces previous editions which may be used)