Burial PermitSTATE OF
DEPARTMENT OF HEALTH Burial - Removal - Transit Permit
Section of Vital Statistics
NAYS OF DECBAnEM—C=—/ _ A OF DEATH
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REMOVAL ❑ OTHER (s,mm, )
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BICNAT OF P ON C C6 OF CO STANCE
Y '711 SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
10-11-05 2M BKS ORDER NO. 9131E
Permit No—
DEATH COMMUNICABLE?
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DATE