Burial Transit PermitDec 1516 04:53p Bergen 2393048411 p.1
State of Florida, Department of Health, Bureau of Vital Statistics
"I BURIAL TRANSIT PERMIT
HEALTH DATE PRINTED:December 15, 2016 TRACKING NUMBER: 2016190968
1. DECEDENT INFORMATION
Name of Deceased Date of Death
PETER WILLIAM M1LCZEK December 10, 2016
Place of Death - County City, Town or Location Name of facility, or street address if not a facilely,
PINELLAS PINELLAS PARK SUN COAST HOSPICE
Name and Address of Funeral HernelDirect Disposal Establishment Fla. Lic. NbdReg. No. Phone Number
BERGEN FUNERAL SERVICE INC F039993 F039996 (600) 336.3761
3107 DAVIS BLVD
NAPLES, FLORIDA, 34104
Funeral Director/Direct Disposer Fla. Lic. NolRag. No.
MICHAEL BLANC F042282
2. BURIAL - TRANSIT PERMIT
The Florida Department of Health, Bureau of Vital Statistics
hereby grants permission to dispose of this body in accordance with Chapter 382, Florida Statutes.
Perna Number: 2ecemb 999 Ill,2027
�-- Date Issued: Decemher 11, 2016
State Registrar
3. AUTHORIZATION for CREMATION, DISSECTION, BURIAL -AT -SEA, or HOSPITAL DISPOSITION
Authorization given by Medical Elmminer District 6 Approval Number. 71613634
4. CEMETERY OR CREMATORY
Place of Disposition: SCIENCE CARE ANATOMICAL
Method of Dispasihon: DONATION Date of Disposition:
EDRS maintains all statutorily required information regarding the death record and related
burial transit permit, therefore, returning the permit to the county health department is no
longer required.
If the Place of Final Disposition wishes to retain the copy of the permit fortheir file they may do so.
ON 326E,10112
64V-1.011, Flonda Adrmistrative Code