Bracey Edmonds<I -
STATE OF NEBRASKA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF HEALTH
DIVISION OF VITAL STATISTICS
DISI T
I
permit for the disinterment of the body of
APPLICATION HAVING BEEN MADE for a p now lying buried in
'cc3cl ---------------------
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-----------
--
-
------------Cemetery, to the --------------- ------
--
(Give City, Town or Township)
-- j t'IP �%_9i2 -
-day of
' ---------- County of -----------
a----- -
- - - , `i ------------------------
State of Nebraska, and who died on the -__-____--_------------------ L4 days, the cause of death
----------April----- --------- -- --- ---
----- 1--95`_Z_, aged ----��---Years,------��----months>-----------
_ on death certificate No---------------------
Fietilaatt---------------------------------------
being ---------------------
-------- ---- ---
this is to certify that permission is hereby given for such disinterment and removal y------------------------------------------
-- -
to------igC)------01i--Celt----' ----------------------------------------
-----------%—�'"l^� -- ---- ----- ---- --- - --
It14_i ---------------- -- - -Town, or Township)
a -- _ _ _--- Of -------- (State whether City,
Cemetery in the-------------------tawal--------------
0��, ��x'%; __ to take
0171 n, iv�0 ----- ------State of -------------------------------------------------------------------------------
of
------------------ - _-------------
--------------- ----------------
effect upon approval of the local board of health. at the ________----------- --fit=-City or Tow11>
that
B:Laj.x l�lobx'a'Sk ______ ____ _____ it being understood heaRegulat ons f the nothingherein
of h Pubic
--c - P or releasing
of______________ anywise modifying
rans-
deemed as contravening or in
the and provi rther, that where the
Welfare governing the Transportation of Corpse or overned requirement
s for Transportation rther, h a
portation Companies and Common Carriers will be g
contiguous cemetery,
distinterment is for the purpose of reinterment in another par of he same cemetery, or
public conveyance. . r
the removal shall not be made by any p r
--
------
-
----- --------- -
-
---------� State Registrar.
s
lication for distinterment and removal is hereby approved by the local- b and of..health
The foregoing app / ®�
l!t ` ----- ---------
of the -------------------- (City
------ - - -
(City or Town) �7
i' 191
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State of Nebraska, this___-� ------ day of -----------
- b
----------- -
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Chairman Local Board of Healt .
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Attest_ -------=------ - - -
S [t a city or town 1 Secretary Local Board of Health.
1
affix corporate seal J
The ORIGINAL permit should be attache the transportation
the disinterment cionprm takes place
DUPLICATE is to be retained by the cemeteryit, and ompa.ny the body to destination. The