Mary-Lizzie-Charlie-Ray W. Loftis� � 1
STATE OF/NEBRASKA C
DEPARTMENT OF HEALTH
DIVISION OF VITAL STATISTICS
DISINTERMENT PERMIT
bods s
APPLICATION HAVING BEEN MADE for a permit for the disinterment of the-hedg oT
.Mary.,.. Z,4f. is,..Lizzie..Loftia, Claas°li.e..r,o.itas.,.Ray. V�...LQf tis ...... now lying buried in
..New. Eng18Lp4................ Cemetery, in the ....... ` ' �'1' .......................
(Give City, Town or Township)
of ............Herman ...................... County of ........ ...... jdVaahii;gt;on....................
State of Nebraska, and who died on thebetwe.en . the. years _1683. -and - 1.90.1 • • . • • • • • . • • . • • • day of
...... I ........................... 1...... , aged ...... years, ....... months, ....... days, the cause of death
being................................................................. on death certificate No............ .
this is to certify that permission is hereby given for such disinterment and removal by .......................
....... P.ri.vate..convey.ante.................... to ...........................
Cemetery in the T own . of ...................Bl&3 r...................... .
(State whether City, Town or Township)
County of ......IVashinggi?.............. State of................... Nebr..................... to take
effect upon approval of the local board of health at the .................. Town.. .. ................... .
(City or Town)
He 17man
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 Health
governing the Transportation of Corpse or the requirements for Transportation Permit, and all Transporta-
tion Companies and Common Carriers will be governed accordingly; and provided further, that where the dis-
interment is for the purpose of reinterment in another part of the same cemetery or in a contiguous cem6tery,
the removal shall not be made by any public conveyance.
State Registrar.
The foregoing applicati n for disinterment and removal is hereby approved by the local board of health
ofthe ............. ............................................... of .........................
(City or Town) JJ//
State of Nebraska, this .. f... day of .... ...................... 19 �`.rJ
If a city or town Attest
.........&r7.,��Pcal-B-o
.....
affix corporate seal oar
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.