Mosher, Caroline PERMIT FOR DISPOSITION OF HUMAN REMAINS
INDIANA STATE BOARD OF HEALTH
C D PERMIT NO
z▪ NAME OF DECEASED (Last) (First) (Middle) DATE OF DEATH (Month,day,year)
MOSHFR CAROITNF N.
October 20, 1979
3 (State)
D SEX • COLOR OR RACE AGE PLACE OF DEATH (City or township) (County)I- Female ( White 43 South Bend St. JOseph Indiana
N (City or township,county,State)
Z METHOD OF DISPOSAL NAME OF CEMETERY OR CREMATORY
a BURIAL 0 CREMATION
Xj REMOVAL ❑OTHER (Specify) Regon & Denny Funeral Home,Inc. Glen Falls/Warren County/New Yo
TE NAME OF FUNERAL ESTABLISHMENT
BUSINESS ADDRESS
•
• Guisinger Colonial Chapel 3718 S. Michigan St. , South Bend, Indiana 46614
U BURIAL TRANSIT PERMIT ISSUED FROM PROVISIONAL
`• PROPERLY EXECUTED CERTIFICATE OF DEATH
RECEIVED CERTIFICATE OF DEATH
w DATE LOCAL NUMBER DATE LOCAL NUMBER
7
2 A CERTIFICATE OF DEATH OR PROVISIONAL CERTIFICATE OF DEATH having been filed as required by law, permission is hereby given for transportation and
I- disposition of this body.
a SIGNATURE OF L AL A t OFF ER (Address) DATE ISSUED (Month,day, year)
II
a.
B ALMA
Lnc 4/ • 3ct ber 21 , 1979
1'/,y✓aq / �j�.,
F DATE OF INTE T, CREMATION 0 EMOVAL S ATU,R E� N OR PERSON IN�`d'�//f/i `^^ryr
- •
SBH 06-006 • 5