Koudla, Ivan Illinois Department of Public Health PERMIT FOR DISPOSITION
Division of Vital Records OF DEAD HUMAN BODY
NAME OF DECEASED DATE OF DEATH
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PLACE/OF DEATH(STREET OR INSTITUTION) CIITTYY COUNTY VETERAN
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PLACE OF DISPOSITION(NAME AND LOCATION OF CEMETERY,CREMATORY) a
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IF ANY OF THE ABOVE ITEMS ARE CHECKED,THIS PERMIT MUST BE SIGNED BY THE LOCAL REGISTRAR
PRIOR TO DISPOSAL OF THE BODY.
NAME AND ADD SS OF PHYSICIAN WHO WILL SIGN DEATH CERTIFICATE
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I CERTIFY I HAVE CO ED THE PHYSICIAN AN E/SHE WILL SIGN DEATH CERTIFICATE.
SIGNED , FUNERAL DIRECTOR
FUNERAL HOME NAME AND ADDRESS
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RE TRAR SIGNATURE DIST NO. DATE P RMIT ISSUED
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REGISTRAR ADDRESS ( L.-‘.
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