Bisher, Berte E1ERY RE ±kcT '�: A`""""" ..* STATE OF ILLINOIS PERMIT NO.`'"' �
.. PERM T FO QISP ITION.OF DEAD FILI/p['A'N BODY
DECEASED NAME FIRST , l LAST SEX 4 DATE OF DE TI{ (MGNTH,DAY,YEAR)
�r
i
AGE LAST PLACE OF DEATIi COUNTY ICI Y,.TWVN,,,,TWP. OR ISTR( `NU BER U S ERAN
OTHY3k)
,r ` le.k lk N.
tt Q
CAUSE OF
ORI 1 4 Z
ty
v) ❑ HOLD BODY BEYOND 72 HOURS l " 1SEATH• ,,DISPOSITION AUTH
COu)
C
INTERMENT, ON (DATE) _ CE F DISR{951TIQN (N9A AND LOCATION OF1C I TERY, R fAAC�yRY OR ABO TORY) p
REMATION, ON (DATE) r= 1. PJ,' ,t i L. O
O ~
❑ TRANSIT r] DIS:PdTtn'MENT PL4 E OF DI NTERAAM���rNT (NAME.j.N�q�ATIpN) .„,----
C 1l�/L J "e `' C
c !' err r
N ❑ SCIENTIFIC STUDY I l F T .w,.y�"'..,i,! a L (yF 7at-y o
SAr' [L1
A' _ . THE REQUIREMENTS O LINOIS LAW HAVFNG hctN MET, THIS PE MIT 0 DISPOSE OF A DEAD HUMAN BODY IS ISSUED TO: ) R
r
O ____ FUNERAL DIRECTOR;. ILL. LICENSE NO. *.I Z
. ' d
O ADDRESS: ~_-
U
DATE: (SIGNED) • LOCAL REGISTRAR Q
>' .>• ADDRESS: CHICAGO BOARD OF.HEALTH , '
REGISTRATION BY:
w `16.1® Chicago Civic Center, Rolm) 105
DISTRICT NO. Concourse Level, Chicago 60602 '
- SEXTON'S ENDORSEMENT: :.
WAS INTERRED CREMATED 1L 7
THE BoDy ACCOMPANYING THIS PERMIT WAS RECEIVED AND W
ON 19 IN_ CEMETERY OR CREMATORY— NAME .-
c)
LOCATED AT (SIGNED) _F
l+ SEXTON
GRAVE OR VAULT: BLOCK `LvOT Got.
i SEE OTHER SIDE
I
VR 204 (P.O. 40356-100M—4/72) ILLINOIS DEPARTMENT OF PUBLIC HEALTH -SPRINGFIELD