De Vol, Clarence VS 306 s Rev. 9/68 Department of Public Health and Welfare of Missouri
DIVISION OF HEALTH Reg. Dist. No.
• PERMIT FOR DI )SIT F DEAD HUMAN BODY Permit Now- � y-73
Full Name of De dent: //,t,i, � Age Sex N o
Place of Death: County of +steepll
Date of Death_m. / a of , 9.r.d. I 1Contagious z
Cause of Death: Non Copt gi s
Medical Attendant Af- . Addres �� o
o
��� H
This permit to disp f dead human body is i to: �� � t� —/- z—e 1t"
Funeral Direct ddress >7. o
Embalmer Missouri License No. r
z
Method of Disposition: (Specify)
D.W.Newcommers Kansas City, Missouti a.
� rial 0 Scientific Study Destination: m
Cremation 0 Reinterment Or (Name of cemetery, crematory or Taboratory) o
0 Transit 0 Change in destination Place of Reinterment: Q
of burial (Town) tate)
(—
Permit issued b . to �-- 7 N
< R. ENE C I-I . _ .i, (Local Registrar) (—
Address
COULD t i '�I_` (Deputy) cc
r W
SYt(yNvf1E1J, i..:.,�. : a-
Sexton's Endorsement: The body was received and was(t.{-cremated(W(interred a.,
on 7 4-7‘. i /.? , 19742, in CEMETERY, -
located at Egned 6" ( /, , Sexton
This permit must be en orsed by the sexton (or by(tKe Funl Direct when there is no sexton) and returned to the above Registrar
within 10 days.