Form DFS-N1-1752 "Direct Disposal Establishment - Monthly Report of Cases Embalmed and Bodies Handled" - Florida

What Is Form DFS-N1-1752?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2006;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DFS-N1-1752 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download Form DFS-N1-1752 "Direct Disposal Establishment - Monthly Report of Cases Embalmed and Bodies Handled" - Florida

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Page background image
D
D
E
-- M
R
C
E
B
H
IRECT
ISPOSAL
STABLISHMENT
ONTHLY
EPORT OF
ASES
MBALMED AND
ODIES
ANDLED
Mail to: Division of Funeral, Cemetery & Consumer Services, Attn: Monthly Reports, Larson Building, 200 E. Gaines Street, Tallahassee FL 32399
Name of direct disposal establishment:
License #:
Phone #: (
)
-
This report is for
Month:
Year:
Direct disposal establishment address:
Name and license # of facility(s) where bodies are refrigerated:
Name and license # of removal service(s) used in this reporting period:
Name and license # of facility(s) where bodies are cremated:
Name of deceased
Date of death
Date of disposal
License # of cinerator
Direct disposer who
County of death
Burial transit permit #
mm/dd/yy
mm/dd/yy
facility
completed contract
TOTAL BODIES REPORTED:
We the undersigned depose and say that we personally supervised the cases indicated above. Direct disposition was accomplished in accordance with: rule 69K, Florida Administrative Code (or
successor rules), and Part 6 of Chapter 497, Florida Statutes.
Signature of Direct Disposer & License #
Signature of Direct Disposer & License #
Signature of funeral director or direct disposer in charge:
Signature of Direct Disposer & License #
Signature of Direct Disposer & License #
License number of licensee in charge
Signature of Direct Disposer & License #
Signature of Direct Disposer & License #
Date signed
Page
of
/
/
DFS-N1-1752 “Direct Disposal Establishment – Monthly Report of Cases Embalmed and Bodies Handled,”
Rev. 10/06
D
D
E
-- M
R
C
E
B
H
IRECT
ISPOSAL
STABLISHMENT
ONTHLY
EPORT OF
ASES
MBALMED AND
ODIES
ANDLED
Mail to: Division of Funeral, Cemetery & Consumer Services, Attn: Monthly Reports, Larson Building, 200 E. Gaines Street, Tallahassee FL 32399
Name of direct disposal establishment:
License #:
Phone #: (
)
-
This report is for
Month:
Year:
Direct disposal establishment address:
Name and license # of facility(s) where bodies are refrigerated:
Name and license # of removal service(s) used in this reporting period:
Name and license # of facility(s) where bodies are cremated:
Name of deceased
Date of death
Date of disposal
License # of cinerator
Direct disposer who
County of death
Burial transit permit #
mm/dd/yy
mm/dd/yy
facility
completed contract
TOTAL BODIES REPORTED:
We the undersigned depose and say that we personally supervised the cases indicated above. Direct disposition was accomplished in accordance with: rule 69K, Florida Administrative Code (or
successor rules), and Part 6 of Chapter 497, Florida Statutes.
Signature of Direct Disposer & License #
Signature of Direct Disposer & License #
Signature of funeral director or direct disposer in charge:
Signature of Direct Disposer & License #
Signature of Direct Disposer & License #
License number of licensee in charge
Signature of Direct Disposer & License #
Signature of Direct Disposer & License #
Date signed
Page
of
/
/
DFS-N1-1752 “Direct Disposal Establishment – Monthly Report of Cases Embalmed and Bodies Handled,”
Rev. 10/06