Marguerite HornFLORIDA DEPARTMENT OF
State of Florida, Department of Health, Vital Statistics
HE LT APPLICATION FOR BURIAL - TRANSIT PERMIT
A (TYPE) Date Month Day Year
First Middle Last
1. Name of of
Deceased Death 1`/laY 2
Horn , 2008
City,own Tor Location Name of (If neither, give street address)
2. Place of Death Hosp. or
County Inst. River Garden Hebrew Home
Phone Number
Address
3. Name edical
Certifier Dr. Edgar Alvarez 11401 Old St. Augustine Road 904-260-1818
Medical Examiner Physician Jacksonville FL 32258
4. Name of Funeral Home/Direct Disposal Address
Fla. Lic. No./Reg. No. Phone No. (Area Code)
Establishment 4115 Hendricks Avenue FH 363 904-346-3808
C eck a, ® The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box was contacted on 5/5/08
b
He/she verified that this death was from natural causes, that there was no accident Wiii complete®and sign the death,
and that
certification of cause of death within 72 hours. was contacted on He/she verified that
c. , Medical Examiner, will complete and sign the
medical certification of use of death within 72 hours.F.E. No./Reg. No. Date Signed
6. Funeral Director/ ,� Sig, at re 5/5/08
Direct Disposer
BURIAL - TRANSIT PERMIT Permit No. 2008-363-136
B.
Permission is hereby granted to dispose of this body. physician has
five (5) day extension of time for filing the death certiable tccomplete the medicalte (exclusive of kcertificat on of cause of -death sectends) has been requested and ion of the death certificate within
been contacted by the funeral director and will not Y
72 hours.
No extension of time for filing the death certificate has been requested. Date Certificate
` ` Date
ZSubregistrar
istrar or I Issued: 5/5/08 Due: 5/14/08
Signature
C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Date
Approval Number:
gave authorization by telephone to
Medical Examiner, Date
Funeral Director/Direct Disposer.
The Medical Examiners approval must be obtained before disposal by any of the above methods. Awaiting period of 48 hours after death is
required for all cremations.
CEMETERY OR CREMATORY
D. Place of Disposition
Method of Disposition:
®BURIAL
®STORAGE Date of Disposition
®CREMATION ®OTHER (Specify)
Signature of Sexton 1
or Person -in -Charge J
This ermit must be endorsed by the Sexton or person -in= coun(or
owherthe e dFunedoDoccu�redirect Disposer when there is no Sexton) and returned
within 10 days to the local County Health Department In theY
Distribution: white: cemetery or crematory
Yellow: Funeral Director or Direct Disposer
(Stock Number:: 57 �tes all 40-Ono-02&2previous editions)
Pink: Local Registrar