Roma Ruth TegtSTATE OF NEBRASKA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF HEALTH
DIVISION OF VITAL STATISTICS
APPLICATION HAVING BEEN MADE for a permit for the disinterment of the body of
ow lying buried in
-------------- -----Blair ---------- -------------Cemetery, in the -------------------------- town
--------------------------------------------
(Give City, Town or Township)
Tb
-------------------------- ------------------ 7 ---- -------- ------ `County of ------------ , a -in , . ,n 7------------- -------------------------------
State
-- ------- ----------------State of Nebraska, and who died on the. ------------------------------------- 2n& ----------- _-___-___:________-__-___-________-______-__-____ day of
-------------------------------------------- ----- 1- —9X-1, aged-----L----Years,--- ------months,------' -days, the cause of death
being---------------------------------p=.-G�i�i3-ta--------------------------------------------------------on death certificate No ---------------------
this is to certify that permission is hereby given for such disinterment and removal by ------------------------------------------
---------------Ya:-C13� +C,iTGLs1-------------------------- to -- --- y i�G'------` t----------
Cemeteryin the-----------------tt------------------------------------- of ---------------------------fir ont--------------------------------------
(State whether City, Town, or Township)
Dodg
County of ---- --------------------------------------- ----- ------State of------------------------------------- --------------------------------------- to take
effect upon approval of the local board of health at the___________________-_____-_____--_______________-__-_--__-_________
(City or Town)
y '�b�o
of_________________ ________ _______________________.-_____-____--__-_____it being understood and provided that nothing herein shall be
deemed as contravening or in anywise modifying or releasing the Regulations of the Department of Public
Welfare governing the Transportation of Corpse or the requirements for Transportation Permit, and all Trans-
portation Companies and Common Carriers will be governed accordingly;,,and provided further, that where the
distinterment is for the purpose of reinterment in another part of the same ctiemetery, or in a contiguous cemetery,
the removal shall not be made by any public conveyance. a.
K _
tate egistrar.
The for oin application for distinterment and removal is hereby approved by the local board of health
of the --------------------------------------------------------------- of - - ----
-------------------
(City or Town)
State of Nebraska, this___ _______day of_____ __ --------------------------------------------------- 19
Chairma Local Board of Health.
J ( , i
1 _
If a city or town 1 Attest- - - ---- --------- - - --------------
--------------------------
l affix corporate seal j Secretary Local Board of Health.
The ORIGINAL permit should be attached to the transportation permit, and accompany the body to destination. The
DUPLICATE is' to be ' retained by the cemetery where the disinterment takes place.