Dennison, Lori .,��` � PROVISIONAL NOTIFICATION OF DEAT4I -BURIAL TRANSIT PERMIT # � /
State Fonn 38220(R21 )/SDH 06-093-32
v,-;,.../.: 2� COUNTY HEALTH DEPARTMENT 2 4 7 8 4 3
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INSTRUCTION: Please type or print clearly
A REPORT OF DEATH
(To be completed by'ac,it, e. ..cc., e.
Name of deceased(First middle,last) Date of death(month,day,year) Time of death(local) AM
Lo'�t t L L . 1•11.1t.No(`i 4-a/-.ICti tt f'7 M
County of death City of death Age Race Sex❑ Male
D c R e 0 a i I:a.R.T" 3 8 4 .® Female
Place of death(If not facility such as hospital,nursing home,etc.give street address)
a 4 - e R cu-1-.e a (•c
Name of Medical Certifier(official certifier of cause of death) Telephone number
3-4 c"1)C f C A l l40_11A,../ ( 012--)51-2 3u3
Address of Medical Certifier(number and street city,state,and ZIP code)
36 ( t-k- - - ,_u e -t , oz-s—
B RELEASE
/To be campie:e persc� ^a.l- "✓ :, ___ =
Authorization is hereby granted to release the remains of the above named to:
Name of funeral home , City State
c'C-e, b ta.,° (12v )--6,W V-4."C-1-fin i'zj +-1
�+'*s. - , - •.. Name of next of kin or legal repreve authorizing release
`�%� 1_4;/ A.._ 8-t-evc"? . Ct t l4,_la t r
O BURIAL-TRANSIT PERMIT
(To be completed by a -. .
I,representingZ c ' 1: sp e AL- i /6 Gt , a6
name of funeral home city state telephone number
hereby accept the remains of the above named and agree to secure and file a complete certificate of death within the time lira established by law.
Sig • or . ... Printer Lice F - Director lndiarha Funeral Director Licensenuumm`ber
�
A certificate of death having been filed or a provisional notification of death received as required by law,permission is hereby given for transportation and
disposition of the remains-except for crematio which requires a completed certificate of death.
Signature of Health Officer r Local number Date tiled(month,day,year)
D 1•/ RESIDENCE
To be completed by'..-era o
Last known county of residence Last known address of deceased(number and street city,state,and ZIP code)
Hcrh.l'Vor, I3;35 s,^ V+neenk (314k ^ ht:cS IA) 41 ,0 .
Address(es)two(2)years prior to death 1 (number and sheet city,state,and ZIP code)
(if different)
(number and street city,state,and ZIP code)
1
E DISPOSITION
(To be signed by sexton of cemeter, c e e
Name of cemetery I crematory Dale of disposition(month,day,year) Date of cremation(month,day,year)
't l (`vim- 5- 10-t3 -(3-13
Place of disposition(City,county, -,r -,and ZIP code)
Method of disposition(check all that apply) ❑ Burial et i Cremation ❑ Entombment ❑ Inumment ❑ Removed from State
0 Donation 0 Scattering(location)
Cremains returned to: ; Funeral Director _f ; Family Cemetery
F Utm1:1 t. Date(month,day,Year)
Signature of sexton or crematory representative
A- /13 15
DISTRIBUTION: White copy-Health Department copy to a... pany the body toils disposition. Must be signed by the sexton of the cemetery or the representative of the crematory,
and returned to health department in the county where the death occurred within two(2)days after burial or cremation. Copies may be made for faxing. Contact
local health department for out-of-state shipment.
Canary copy-Cemetery/Crematory copy for their records.
Pink copy -To be mailed by the facility where the death occurred to the local health department within twenty four(24)hours following death. Copies of the white
form may be made by the facility for its'records and for faxing in lieu of mating.