Eggleston, Sue Anne MONTANA DEPARTMENT OF
PUBLIC HEALTH AND HUMAN SERVICES L>�
Vital Statistics Bureau
PO BOX 4210, Helena, MT 59604-4210
AUTHORIZATION
FOR REMOVAL, TRANSPORTATION AND FINAL DISPOSITION OF A DEAD BODY
❑ LOCALORIGINAL
REGISTRAR ❑ ONE NE NE COPY TO 0
IN COPY TO ARGE OF DISPOSITION MORTUARY/PERSON ❑ ONE COPY TO CEMETERY/CREMATORY
OR TO ACCOMPANY REMAINS OUT-OF STATE
Machine or facsimile copies of this form shall be valid for all purposes
If fetal death,check box: ❑ and provide date for mother or fetus as appropriate
NAME: Sue Anne Eggleston DATE OF BIRTH: August 02, 1945
Z
W SOCIAL SECURITY NUMBER: 052-36-1011 ❑ Male ® Female
0
W DIED(or was found)ON: August 25,2022
W
AT: 856 Woodland Hills Dr
Helena
IN: Lewis and Clark
COUNTY.
TO BE COMPLETED BY INDIVIDUAL AUTHORIZING REMOVAL.TRANSPORTATION AND FINAL DISPOSITION:
I HEREBY AUTHORIZE THE REMOVAL,TRANSPORTATION AND FINAL DISPOSITION OF THE REMAINS OF THE ABOVE-NAMED
DECEDENT(OR IDENTIFIED FETUS)PURSUANT TO MY AUTHORITY UNDER 50-15-4-5,M.C.A
I CERTIFY THAT I AM:
z ❑THE CORONER HAVING JURISDICTION ®A MORTICIAN LICENSED UNDER 37-19-302,M.C.A.
Z ❑THE PHYSICIAN IN ATTENDANCE AT DEATH or THE PHYSICIAN'S DESIGNEE
August 25,2022 3344
N signature date Montana license#(if any)
OJoseph Trainer Anderson Stevenson Wilke Funeral Home
= name(typed or printed) name of agency or firm represented(if applicable)
F— 3750 N Montana Ave Helena MT 59602
address city state zip
If authorization is by person other than a mortician licensed under 37-19-302,M.CA.
name and address of mortuary/person in charge of disposition and filing of death certificate under 50-15-403,M.CA.
name(typed or printed) firm(if applicable)
address city state zip
Electronic signature
Z Cremation Authorization: Scott Lindgren per MCA 30-18-106 August 29,2022
date signed
~ CEMETERY OR CREMATORY AUTHORITY MAY COMPLETE
L7
Q Mountain Valley Crematory
W date of disposition cemetery or crematory name El buried cremated
(.0 Helena Lewis and Clark MT
O city of disposition county state sexton or person in charge
Eggleston —�
NAME Sue Anne Eggleston Age: 77 ( LF
Lot Owner: Edgar & Sue Eggleston `!
Lot# Erie 1 3 A Grave# 1
Case: urn
Died: 8.2 5.2 2 Interred: 9. 1 7.2 2
Funeral Home: Anderson Stevenson Wilke FH
Helena MT
Cemetery: Pine View
EGGLESTON Lot No. 13A
Address 180 AA Deakins Road Jonesborough nn. 37659 Section No. ERIE
Owner Edgar & Sue Eggleston LIFPlot
_ Fa-it/dab CM
Date 7/7/2014
Superficial ft. ek 67
Location Bounded on East Vacant, Bounded south by path, bounded west vacant
hounded cm l\Inrth vacant
Corner Posts
Remarks
Deed No. (and changes) u 5g
Payment Record Paid in full $1200. Queensbury residences
Record of IntermentsECA
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Form No. 01