Wyman, Maria , 4 I
if 71
Nei," y CR STATE CEPARTMEN- OF HEAL-H
Burial - Transit Permit
Vital Ret.:nrds Sebtior
• Name Fri.,:,...r- ' -- — i-Ait.dir., t ast r.,
,zeqc.: 1
— 1
NAOcr la l:-- ik),V ma.,3 q rYlo ie,
Dal, LA Dpath 0-. ... 11 v,-„.1.:,tefig -:-...,t US rme-ei Fore-es
1 - 8--Z-01(4) ----7 3 ‘iVar ur Dates KJ 0 „
place ul Death -,uspital Instituti- h Or
n cr ..ii !.,.... .. Tok VI i rr Secati-Dif;Sp r 1 n3S. '
c.itreet Address friCrk .14.(Aoltill- , j
,173 Manner if DeatlX1 _Jr 3 :4 r rideterm.p : Peridin
Nattrra`: '..- irrin , Mr:dent I-- Hi:Inn:de i uici.,e. ig
11!
L—.i.--...I
Cirrirth: stancri-s Investination
0 --
tu er1,;.:0.1 Cerriticl ,r Nan:: Titlr-,
.3 bh p n CI kkt-r)g NI I)
-4011,,70„,:yo ,„: vr a!it'c1/4,...)CUrLd293JIMA_ Li Sni
-,
;Cremation
. .
pkiirirr.5-
DaN-, U12..12_rtbUir_.9 me".ery or Crern• ry
1 IV \At
r.717.-m(Pied
1... Chi"r:11 : &Va-f-0,.setek 3-r I enS NY
E3D 1-,:tic:mr::itcapi:1:16,21 ....:: 1 k )1,...,h, irt dr':ibe. Pg•ster N.irib..A
'f. LiBorlai
Z I-1 Removal Lo id or field
0-11„..,,,,i n
1...„*.""' '-'..."''' Aildre4,';
' ' Hnid
.
JO Date F',;t It ....1
in ETrati*portoror, Shipment
5 by CorrirriLAI DES:MillICH
Carrier
Datr7.- Cemetery Address
El Doi'irterititilit
...
I[ ]
, 4,.., rElerrhent Date Cemetery Address
..1_
- - -- i
i Perm-t IF.Sireci to Registration Number
Name or Funeral Hun [Bye ) _ .0 '
....t.t-r- -../1 _i -HE)M- 1
e._ Inc 0a.4- i /
, kith ess
c. 'f e-i'llk rCle) St Lo1/4_- _it_ LutzLriu ivy 12
_ .
Niarne ut t Liner al Finn Makrig Distiosition r_..i to W11-b-i
I- Per-awls are Shipped i' t"..,"ther than Abpve
X Address
ir
0..,'
f Permission is ere y granted to dispose of the human rernrerris s=rie , S Indies ,
Mire Issued 1 I i O(LQ2 Registrar ot ',Nal .-.Etatistics
ti
, I.
District Niirrither 4501 21.3cl' ftill -C,. k, & ()TIC' ilJL-
,
i rt-frrtfy !har trio Ionians :-4 triff deoncint-i-idencr!,.fid ithave , ere disbosed u i accordhme with this permit on
f Daze Of 11-5POS I tli)11 (I 1)116 ,, ,,pl , ,- Di,,,,,, ,,,i , ;()„%., Co.y.cttort,i--
21
lux
or.
ref .-c).‘"':AV f kr...,,rrit.4.•,r i
1 !in Name ol Sexton or person in Criarqe ,-.-.4 PrenTses abs/fi.-..- itsitat i
F
ILIU , (146$46164
f
4 Si inatur .. , ......._..,
..,,,er:i
:OH-1555 :0212004i