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Simmons, Florence IVGVV I V FUN , I/-%t G WI. r rw-t I iv'Llv1 Vf II G/'%L 117 Vital Records Section Burial - Transit Permit- `'Eeam'y t(• S Name First Middle Last Sex Qreat/ce, "a. ,cn c / - Date of Death Age If Veteran of U.S.Armed Forces, D j -' —1, 9/ War or Dates 0 H Place of Death / Hospital, Institution or Fa Ci . To •r Village r cipe,7.Sb L-ve Street Address /a p,!i✓00cf/fl/e, p Man - of Death F/ Natural Cause IDA4cident D Homicide ID Suicide riUndetermined ri Pending Circumstances Investigation Q.Lij^ Medical Certifier Name r. Title 0 1v / `c. t /e escO t'"` Address Death Certificate Filed Distnumber / R ter Number City�fow Ir Village(gle P. 4 t✓► -Y Co I 'D8urial Date Cemetery or Crematory (�3-a3 -ao1 A47P, vP.IA/ / /' []Entombment Address Q Cremation i ti.c,k. ,r /4bci�G 4-t Polo S d f,v /q FO Date Place Removed 2❑Removal and/or Held and/or Address 1=';' Hold f 0 Date Point of IL J Transportation Shipment a by Common Destination Carrier El Disinterment Date Cemetery Address .� ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home lArturaid . Kcr Funerc 00ty 011 30 Address 11 Lai-aye'I*e Spree+ , f ueenSC ry, We_ ,-J ` or-1L 1 Z Yo Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address ir t] Permission is hereby. ranted to dispose of the human emains described ab ye as indicated. Date Issued egistrar of Vital Statistics�� ' )Il-L �, (signature) District Number 5?..0 Place l © --, O-c0 TSb �:,; I certify that the remains of the decedent identified above were disposed of in ccordance wi this permit on: Lit Date of Disposition 3-Zs-t Z Place of Disposition I r`e U e v rtirrefdti W (address) 0, (section) / 7 (lot number) (grave number) L Name of Sexton or Pers n in Charg of Premises 7 rd r Sit 2 please pant) Ili / Signature Title aZeihi i-VOL (over) DOH-1555 (02/2004)