Harold Philip Palmer

Butler Township, Clark Co., Wisconsin

STATE OF FLORIDA

DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES

VITAL STATISTICS

APPLICATION FOR BURIAL – TRANSIT PERMIT

Check                    A  o       A completed certificate of death accompanies this application.

One

                                B.  T      Dr. Edward F. Jukes was contacted on February 16, 1981.

He has assured me this death was from natural causes and that he

 will complete and sign the medical certification of cause of death.

                C.  o      The attending physician was unavailable or this death comes

within the Medical Examiners jurisdiction.  The body was released

to me by ________________________on ___________________.

                         Dave L Holt                                              2213                                           February 17, 1981

                            (Signature)                                             Fla. Lic. No.)                                       (Date Signed)

______________________________________________________________________

                                                                                                          Permit

                                          BURIAL TRANSIT PERMIT             No.        162-34

Permission is hereby granted to dispose of this body by burial, transportation out of state, storage of cremation.  For cremation a waiting period of 48 hours after death must be observed and the Medical Examiner’s approval must also be obtained.

o                  A five day extension of time for filing the death certificate has

been requested and granted.

_______________________________________________________________________

Signature of                                                                                          Date

Registrar                     James Lovett                                  Issued  February 17, 1981_______

CEMETERY OR CREMATORY

Method of Disposition: Burial                                    Date of Disposition:  February 19, 1981

                                                                                    Place of Disposition:  Butler Cemetery

Signature of Sexton

Or Person in Charge                        Arthur G. Morrison______________________________

This permit must be endorsed by the sexton or person in charge (or by the funeral director when there is no Sexton) and returned within 10 days to the local county health department.