Marie V. PertersenG$.�OFTtiC�E,Bjq
ANICU URE iM
TENNESSEE DEPARTMENT OF HEALTH
OFFICE OF VITAL RECORDS
PERMIT FOR FINAL DISPOSITION OF HUMAN REMAINS
Marie V. Petersen IFemale 11/07/1908 1 08/18/2000
Place of DeathCity or Town, County Name ot Intormant
Soddy Daisy - Tennessee - Hamilton Marilyn P. Gehrke - Daughter
ame of FuneralDirector or Person Actin asSuch) ame o At—tending Physician
I'MAIIMC H. 19QJJC - UlM 1.UQ
Address o unera erector or erson ctmg as uc
P.O. Box 3027 Chattanooga, TN. 37404
I hereby apply for a permit for the final disposition of the remains of the above named decedent. I agree to
abide by all laws and rules of the Tennessee Department of Health and all other laws pertaining to the
preparation, container, transportation, burial and/or cremation of same. The type permit needed is checked
Application below. If I have not been able to submit a properly completed certificate of death for this person at the
for Permit time of this application, I agree to file within three days the required record with the local registrar in the
county where the death occurred.
Signat �l7Z� — Chattanooga, Tn. 37404
Address P.O. Box 3027
TYPE OF PERMIT REQUESTED (Check all that are applicable.)
O Burial O Cremation O Disinterment
4 Transit O Scientific Use O Reinterment
PH -1687 (Rev. 8/97) RDA 1468
I
Name and Address of Cemetery where Remains are to be Interred
Burial
Blair Cemetery - Blair, Nebraska
Name and Address of Crematory where Remains are to be Cremated
Cremation
From To
Transit
Chattanooga, Tn. Blair, Nebraska
Removed From (Name and Address of Cemetery)
Disinterment
Place of Reinterment (Name and Address of Cemetery)
Reinterment
Name and Address of Facility Receiving Remains
Scientific Use
I consent to the issuance of the Permit for Final Disposition.
Physician or Medical
Examiner
Signature of Attending Physician or Medical Examiner* Address
*Authorization of the Medical Examiner is required for a cremation permit.
for the final disposition of the remains of the above named is granted for the purpose(s) checked above.
Permit of
Local Registrar
ZT1hirmit
404 S. Moore Road
Signature of Local Registrar East Ridge Address Tn . 37412
1 certify that the disposition of the remains of the above named was made in accordance with this permit on
at
Certification of
Date Place
Person in Charge
of Disposition
Signature
Address
PH -1687 (Rev. 8/97) RDA 1468
I