Baldwin, Almeron UlVI61UN OF VIIALS[Allti I i" Ov1111nL._I nxnv*0n 1 rGnivn 1 PERMIT NO. I ...
HEA272! R12-61 FormVS•14
NAME OF DECEASED DATE OF DEATH
PER A NAL SE/X� AGEL PLACE O EATH (VILLAGE OR CITY) COUNTY
DAON
DECEASED
CAUSE OF DEATH _
MANNER AND BURIAL (91 CREMATION ❑ OTHER
PLACE OF SPECIFYDISPOSAL NAME OF CEMETERY r jY
A SATISFACTORY CERTIFICATE F DEATH OR PROVISIONAL CER IFICATE OF DEATH HAVING BEEN FILED AS REQUIRED BY THE LAWS
OF THIS STATE,PERMISSION TO?FP
OF THE BODY AS INDSCATE ABOVE,IS HEREBY GIVEN TO:
AUTHOR-
IZATION TO FUNERAL -�
DISPOSE OF DIRECTOR ` ADDRESS 3
BODY SIGNATURE OF R GI RAR REGISTRATION DISTRICT NO. DATE OF ISSUE
u c t Gc t' p //
This permit must be retained by superintenden r person in charge of cemetery for a period of (5) five years