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Burial Permit
STATE OF DEPARTI ENT OF HEALTH BurW - Removal -Transit Permit Section of Vital Statistics Registration NAME OF DECEASED _ SEX MA LEI AGR METHOD OF DISPOSAL: ® BURIAL 1-1 CREMATION REMOVAL— El OTHER (swerify) SIGNATURB.tID MORTICIA FUNERAL DIRECTOR SIGNATURE ��x -7.4- -" DATE OF DEATH >At G �� A W G, z df /t> PLACE OF DEATH (I VYYS...r4ww�Ioi 3L�Ar �ARP-4 PLACE OF DISPOSITION (Nawb .f eo.tary . <yereateNrY) rowmw) i i BUSINESS Ii Permit No. DEATH COMMUNICABLE? El Ys © N. (C.uty) (City. VUiat:. we T. -.Mw. Cowwty, Stab) C0.1in+L+) A artlHpt. of Math baelwl brew filed ee reealr.d by b-, wr leeiwa 1. hereby ■fye to diq f JY b.iy. SIGNATURE OF PERSON IN CHARGE OF CONVETANCR AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL I --•— ABOVE OCCURRED ON: (Da") ISSUED