Bennet, Caroline r /17/2011 14:05 86558450136 PAGE 01/01
TENNE_SSEE DEPARTMENT OF HEALTH
OFFICE OF VITAL RECORDS
PERMIT FOR FINAL DISPOSITION OF HUMAN REMAINS
N e of dent 'Sex Date of Birth' 'Data of Drarth
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PI of Cream—City or To n.County e I ant
Name o FuneraaWit�r-(or fson Acting as Such) Name of Physician Who will Certify Death
72454 c .1 451 . ar- 140
T AddressofFuneral At dqr(or PersA�t Acting as_yuch)
I hereby apply for a permit or the final disposition of the remains of the above named decedent. I agree to
abide by all Iowa and rules of the Tennessee Department or Health and all other laws pertaining to the
preparation. Container.transportation,and burial. The type of permit that is needed is checked below. if I
have not been able to submit a properly completed certticate of death for this person at the rime of this
APPLICATION application I agree to file, within three days, the required record with the local or deputy registrar in the
FOR PERMIT dad, where the death
•7,;tyre
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Address
TYPE OF PERMIT REQUESTED-Check all boxes that are applicable
(p Burial IC Transit ❑Scientific Use ❑ Disinterment ❑ Reinterment
Note:This form may NOT be used as a permit for cremation
BURIAL Name and Address of emetery prnere Remains a e be Int rreJd.
TRANSIT From:
)1 d f:/6 t ' t J Q'K i
DISINTERMENTRemoved From(Name end Address of Cemetery)
REINTERMENT Placed(Name and Address of Cemetery)
SCIENTIFIC USE Name end Address of Facility Receivinp Remains
This permit for the final disposition of the remains of the person named above Is granted for the purpOse(s)
e. �PERMIT OF 4�.-�/� � '
LOCAL OR �- 'nature of r uty R tar
DEPUTY fZt
REGISTRAR Address
Vit.etfo1( 77727 /
I certify hat a disposition of the remains of the above named was made in arcorda with this permit on
S4 tf at _t V
CERTIFICATION Date Place
OF PERSON IN
CHARGE OF THE /�
DISPOSITION Signature Cl uAkei(�0top ki,eeti w
1 Pi/ I L$U
Address _ T
When crispoeition Is complete,mail this form to the local or deputy registrar who issued this permit.
PH-1687(Rev. Iu/02) RDA 14Ba
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