Kanz, Tamela State tinois
Permit No.
County of ROCK ISLAND Date Issued 03/23/2011
MEDICAL EXAMINER'S/CORONER'S PERMIT TO CREMATE A DEAD BODY
Full Name of Decedent TAMELA A KANZ
Decedent's Address 2545 24TH STREET, ROCK ISLAND, IL, 61201
TRINITY ROCK ISLAND
Date of Death 03/19/2011 Place of Death 2701 17TH ST, ROCK ISLAND, IL,61201 Time of Death 08:56 AM
Cause of Death SEPSIS
Cause of Death Certified by PAUL WANG , Physician In Charge
Permission to cremate the body of this decedent at PINE VIEW CREMATORIUM,QUEENSBURY,NY
(Name and address of crematory)
has been requested by DEROO FUNERAL HOME, 1611 7TH STREET, MOLINE, IL,61265
(Name and address of funeral home)
MATTHEW THOMPSON Funeral Director's Illinois License No.034016116
(Signature of funeral director)
Being sufficiently informed as to the causes and circumstances of the death of the above described decedent,
permission is hearby granted to cremate the body as requested.
Date 03/23/2011 (Signed) GUSTAFSON, BRIAN WILLIAM , Medical Examiner/Coroner
(MEDICAL EXAMINER/CORONER-WHITE) (CREMATORIUM-CANARY) (REGISTRAR-PINK) FUNERAL DIRECTOR-GOLD)
VR-204.1 (12/05) Printed by Authority of the State of Illinois - P.O.#146099 40M 12/05
THIS PERMIT IS REQUIRED FOR THE CREMATION OF A DEAD HUMAN BODY
1. A dead human body cannot be cremated without this permit. (See section 3-3017 of the
Counties Code, 55 ILCS 5/3-3017, commonly known as The Coroner's Act.)
2. The funeral director can obtain this permit ONLY from the medical examiner/coroner who
made the investigation.
3. The local registrar shall NOT sign the report (VR205) or issue a Permit for Disposition of
Dead Human Body (VR204) authorizing cremation of a dead body, unless the funeral
director presents a completed Medical Examiner's/Coroner's Permit to Cremate a Dead
Human Body plus a complete and satisfactory certificate of death.
4. The report (VR205) or Permit for Disposition of Dead Human Body (VR204) must be
accompanied by the Medical Examiner's/Coroner's Permit to Cremate a Dead Human Body
when presented, with the body, to the crematory.
5. The Medical Examiner's/Coroner's Permit to Cremate a Dead Human Body should be
retained by the crematory and local registrar, subject to examination by the medical
examiner/coroner and/or the Division of Vital Records.