Smith, Albert ORIGINAL PERMIT FOR DISPOSITION OF HUMAN REMAINS
INDIANA STATE BOARD OF HEALTH
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PERMIT NO
Z• NAME OF DECEASED (Last) (First) (Middle) DATE OF DEATH (Month,day,year)
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O SEX COLOR l OR RACE AGE PLACE OF DEATH (City or township) (County) � / (State)
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Z MET D OF DISPOSAL NAME OF CEMETERY OR CREMATORY (CitII or township,county,State)
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t NAME OF FUNERAL ESTABLISHMENT BUSINESS ADDf ESS
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✓• PROPERLY EXECUTED CERTIFICATE OF DEATH BURIAL TRANSIT PERMIT ISSUED FROM PROVISIONAL
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F RECEIVED CERTIFICATE OF DEATH
UI DATE LOCAL NUMBER DATE LOCAL NUMBER
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X A CERTIFICATE OF DEATH OR PROVISIONAL CERTIFICATE OF DEATH having been filed as required by law, permission is hereby given for transportation and
H disposition of this body.
rc• SIGNATURE OF LOCAL HEALTH OFFICER (Address) DATE ISSUED (Month,day,year)
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i D- ATA OF INTERMENT, CREMATION OR REMOVAL - SI A R F SEr
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SBH 113-6
INSTRUCTIONS
HEALTH OFFICER: This burial-transit permit may be issued only upon receipt of a properly executed Certificate of Death or
of a Stillbirth or Provisional Certificate of Death when authorized by State Board of Health.
FUNERAL DIRECTORS: This Disposition (burial-transit) permit is required for any manner of disposition of a dead human
body including interment, storage, cremation or transportation outside the county where death occurred or body was found.
TRANSPORTATION OF BODIES BY COMMON CARRIER: A body dead of cholera, plague, typhus, leprosy, yellow fever, or
smallpox shall not be transported by common carrier unless the body shall have been thoroughly cleansed, embalmed in a man-
ner conforming to standard accepted practice, and all orifices closed with absorbent cotton and the casket hermetically sealed.
Before shipment by train or express,the body must be embalmed;or if that is not practicable,must be enclosed in a tightly sealed
casket or outer case.
SEXTON: It is unlawful for any sexton, or other person in charge of a burial place, to permit burial or other disposition of a
dead body before a Disposition (burial-transit) permit is deposited with him.
This permit shall be endorsed by the sexton (or funeral director where there is no sexton) and carefully preserved.