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o DISPOSITION - REMOVAL PERMIT NO.
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Z NAME OF
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- DECEDENT /1/J .. GC--GC.Lil //71 N .r/i SEX DATE OF d! /�
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}J 1 DATE OF '/('� G� /�� h PLACE Feet
AGE 4t (f� BIRTH /ll/�H�. / oG DEATH L�1L99Lti-a : �4tU_t`I
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CAUSE OF 7, ��� ,///J�
z DEATH .iC/ �.Gr 9/� i ���12'-_.�"�' 1.--4.'L''zl � . "...- '
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5 IN ACCORD WITH THES OF THIS STATE, PERMISSION US HEREBY GIVEN TO THE FUNERAL DIRECTOR NAMED
IX BELO DULY LICENSED BY THE STATE OF COLORADO, TO DISPOSE OF THE BODY IID,ENTIFIED ABOVE.
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NAME O/F FUNER DIRECTOR J JfJC..�-/ AD„D.REJS-y
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RISE SI A6�Z�� LACE .4?k.- `
U DISPOSITION S
Q CEMETERY OR CREMATORY / CITY STATE
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to REGISTRATION DISTRICT ( C �� �� ��
I DATE 7 f �
I- SIGNATURE, OCAL REGISTRAR/cr-
ITEMS BELOW TO BE COMPLET D BY CEMETERY OR CREMATORY OFFICIAL:bE
dLi
. BODY WAS ON 244 // 19O IN LOT // BLOCK SECTION
PLACE`.yl//( /�
_ / (/r
��t-kr ��r� S GNATURE, SEXTON OR PERSON IN C ARGE
AD RS 3 (REV. 2 9-2'A )
READ CAREFULLY
REGISTRAR: A DISPOSITION-REMOVAL PERMIT MAY BE ISSUED ONLY UPON RECEIPT OF A
DEATH CERTIFICATE--NOT BEFORE.
FUNERAL DIRECTOR: A DISPOSITION-REMOVAL PERMIT IS REQUIRED FOR ANY MANNER OF
DISPOSITION OF A DEAD HUMAN BODY OR FETUS, INCLUDING INTERMENT, REMOVAL, STORAGE,
CREMATION, AND TRANSPORTATION.
WHEN USED AS A REMOVAL PERMIT FOR TRANSPORTATION BY COMMON CARRIER, THIS PERMIT
OR A DUPLICATE THEREOF SHOULD BE ENCLOSED IN A STRONG ENVELOPE ATTACHED TO THE SHIPPING
CASE. No SEPARATE REMOVAL PERMIT IS REQUIRED.
BEFORE SHIPMENT BY COMMON CARRIER, THE BODY MUST BE ENCLOSED IN A TIGHTLY SEALED
CONTAINER.
SEXTON: IT IS UNLAWFUL FOR ANY PERSON IN CHARGE OF A BURIAL PLACE OR CREMATORY
TO PERMIT BURIAL OR OTHER DISPOSITION OF A DEAD HUMAN BODY BEFORE A DISPOSITION-
REMOVAL PERMIT IS DEPOSITED WITH HIM.
ALL PERMITS MUST BE ENDORSED, RECORDED IN YOUR SEXTONIS REGISTER, AND FORWARDED
WITHIN FIVE DAYS TO THE LOCAL REGISTRAR OF YOUR TOWN OR COUNTY.