Burial PermitTRANSIT COPY STATE OF ARIZONA REGISTRAR'S ✓
(THIS COPY MUST ACCOMPANY DEPARTMENT OF HEALTH—DIVISION OF HEALTH RECORDS AND STATISTICS FILE NO. 3
BODY TO FINAL DESTINATION) BURIAL -TRANSIT PERMIT ';&Z a.3-
VS -7 REV. 12 -BS 26M 11-70
CEMETERY MGR.: MAIL TRANSIT COPY IN 10 DAYS TO DIVISION OF HEALTH RECORDS, P. 0. BOX 6820.
STATE DEPARTMENT OF HEALTH, PHOENIX, RIZONA 85005
NAME OF A. FIRST B. MIDDLE c. LwsT
SEX
AGE
RACE OR COLOR
DECEASED Hazel Anna Smallwood
White
IDENTIFICATION
2,Female
B_70
G
DATE OF DEATH
PLACE OF DEATH w. TOwx ON CITY N ATE
OF
11_2
Mine Rd. 31ack Canyon City Yavapai Arizona
BI{.
B.
DECEASED
CAUSE OF MOST BE COMPLETED IF BODY IS SNIPPED OUT OF STATE, MOVED BY COMMERCIAL CARRIER, OR A DEATH FROM CERTAIN DISEASES)
DEATH
Acute Heart Failure
7•
� OTHER
[] BURIAL OTHER
HOME A. NAME B. ST. ADDRESS C. CITY AND STATE
MANNER
E] CREMATION (SPECIFY),
1
memory�g 1 31 Grove Ave. Prescott, Arizona
AND
FUNE0. 7 DIREC DR'S A DATE SIGNED
PLACE OF
® REMOVAL
12-11'-72
B. to�
1 f.
DISPOSITION
PLACE OF BURIAL OR NA B. STREET A DRE55 C. CITY ANO STATE
OTHER DISPOSITION
12. J.H. Zam' hn Mortuary Chaska Minnesota
REGISTRAR'S
I3.Ix ACCORDANCE WITH THE LAWS OF THIS STATE AND THE REGULATIONS OF THE STATE DEPARTMENT OPHEALTX PERTAINING TO DEATH CERTIFICATES
AND THE HANDLING OF DEAD HUMAN REMAINS, AUTHORIZATION IS HEREBY GIVEN TO DISPOSE DF THIS BODY IN THE MANNER INDICATED.
AUTHORIZATION
REGISAR'S SIGNATURE
REG. DISTRICT
ATE SI G/N/ED
DISPOSITION
jR
STT
%/!
/J
/ A.-
�j
/�'C — �
A,
IB.
18. /
BODY WASE
CEMETERY F A. B. STREET ADDRESS C. CITY AND STATE
CREMATORY
DISPOSITION
[] BORIED
OF BODY
[-ICREMATEO
ISPFLI Fy)
1e.
GATE 077—DISPOSITION CEME ERY rNAGER'S SIGNA�UR
1
FF��
u/_1
ycl
17.Li OTX EP
I9. 20.1
STATE
ATE R IN STA E FFICE
REGISTRAR 5 SIGNATURE
TITLE
REGISTRAR USE
21
2z A /
22 B
VS -7 REV. 12 -BS 26M 11-70
CEMETERY MGR.: MAIL TRANSIT COPY IN 10 DAYS TO DIVISION OF HEALTH RECORDS, P. 0. BOX 6820.
STATE DEPARTMENT OF HEALTH, PHOENIX, RIZONA 85005