Broawer, Frances G ..%sue PROVISIONAL NOTIFICATION OF DEATH -BURIAL TRANSIT PERMIT
'°441^ State Form 38220(R2/9-06)/SDH 06-093-32 908935
s .. + COUNTY HEALTH DEPARTMENT
INSTRUCTION: Please type or print clearly. 5.
A REPORT OF DEATH
(To be completed by facility where death occurred)
Name of deceased(First,middle,last) n Date of c'ath('onth,day,year) Time of death(local) t•, AM
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Co my of death City
ty of death Age _ Race Sex❑ Male
4 t 1. t/A t k ' ! t_.0-17 Sri :1 li Female
Place of death(If not facility such as hospital,nursing home,etc.give street address)
-,Name of Medical Certifier(officiall certifier of cause ofdeath) Telephone number
?._)v M i C s+i a .J- C % k"?.Y .'t- `; C I ( 3 f-7) 12 S' '
Address of Medical Certifier(number and street,city,state,and ZIP code)
-' C4 LA(Lk'?NI06. 1 741 IY1 C ; •VS ,_. tt.) '`k L` 9.
B RELEASE
(To be completed by poison having authority to release remains)
Authorization is hereby granted to release the remains of the above named to:
Name of f ty,ne`ral home Ci State
•
.1--) a r"1 '�-'. }' l ,I r t �" c _ ,, �,k J)4' .:%O 1 t fn
Sign ure of r resentative of facility releasing remaiins(� p Name_of next of kin or legal representative aputhorizing relent
C BURIAL-TRANSIT PERMIT
(To be completed by funeral director of representative)
I,representing .___Ad I i{r' 44 ✓? 1-{ f /" / C j a ?q 3s l�lp 7 t! c(' �7to /
name of funeral home city state telephone number
hereby accept the remainspLihe above named and agree to secure and file a complete certificate of death within the time limit established by law.
Signatur Kne directtr oC resentative Printed name(\of Indiana'.
/nnddiiana Licensed Funeral Director Indiana Funeral Director License number
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 cremation which requires a completed certified a of death.
Signature of Health Officer
`W i� fYWLocal number Date filed(month,day,year)
t
D RESIDENCE
(To be completed by funeral director)
LA.st nown county of residence Last known a dress of deceased(number bnd street,city., ate,and ZIP code)
: \,.OA TA. ` ,Oa\�,\�\. N (1,,N,1,ac \_\ \' , \ V ; ,_\,,.Ct1 L\V1%ck
Address(es)two(2)years prior to death i (number and street,city,state,and ZIP code)
(if different) • d 1 t. 1 - /4
r(number and street,city,state,and ZIP code)
i
E DISPOSITION
(To be signed by sexton of,.emetery or representative of crematory)
Name of cemetery/crematory � '" Date of disposition(month,day,year) Date of cremation(month,day,year)
PI,: ,of disposition(City,it county,state,and ZIP code) 1
1�-_da\t. .�c\•?fit^) ?,\ .\ ,c-c"Q i\ i V' �".,..L1 \I t, ci \„‹, VTh-,,,(or,',. ..k •
Method of disposition(check all that apply) ❑ Burial ❑ Cremation 0 Entombment 0 Inurnment ' Removed from State
0 Donation ❑ Scattering(location)
Cremains returned to: Funeral Director Family Cemetery
Signature of sexton or crematory representative Date(month,day,year)
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DISTRIBUTION: White copy-Health Department copy to accompany the body to its 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 mailing.
Public Health Law Sec. 4145(2b) 012877
Receipt
Human remains of a delivered on - , 20 A
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
Brower
NAME Frances G. Brower Age: 65
Lot Owner: Glenn & Frances Brower
Lot# Horicon 40 D Grave# 3
Case: Concrete
Died: 9.3 0.21 Interred: 1 0.9.21
Funeral Home: Regan Denny Stafford
Cemetery: Pine View