Olga Rose Schulz.•:•fit:: )+�r •
AUTHORITY FOR FINAL DISPOSITION
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
id0
of Public Holth
and Emironmmc
READ CAREFULLY
• it is unlawful for any person in charge of a burial place or crematory to permit burial or other disposition of a dead human
body or fetus until a final disposition permit has been issued.
• A final disposition permit may be issued only upon registration of a death certificate.
• A final disposition permit is required for any type of disposition of a dead human body or fetus.
• This permit may be used for transporting by common carrier.
• All permits must be endorsed by the sexton, recorded in the sexton's register, and forwarded within five days of disposition
to the local registrar or designee.
This final disposition permit, when completed and bearing thetlon of the deceased named bel wequired signature, constitutes h� accordance with h Section n
rity for burial, interment,
cremation, removal from the state, or other authorized dlspost
25-2-111 C.R.S. 1982. This permit must accompany the remains to their destination.
Date of Death
Name of Decedent 01 a Rose SCHULZ
Nov. 9 2001
Grand Junction Mesa
Sex Fe Age 94 Date of Birth 10 / 16 / 1913 Place of Death City County
14 ctin Mortuar
Name of Funeral Establishment
550 North Avenue, Grand Junction, Colorado 81501
Address of Funeral Establishment Nebraska
Out of State Blair ------
Burial Place Blair City Cemetery _ state
Type of Disposition City
cemetery or crematory
ze
tion
of the re -
I have examined the completed death certificate for the
decedent
ion 25-2-103.. 1CR.S182 nl the county where
mains. (To be signed by the office designated or established Pursuant to Sect
the death occurred.)
Title
Signature
Date
Address M HFA ,
510 29-112 Road
C Juncooft, GO 91504
by the cemetery or crematory official.
Items below are to be completede days of dispositionlcharge,1-time person in
to the local regstrars or des gnee.l
director may sign as sexton. This form must then be forwarded within
D� In Lot 1 Block
3 5ecten
Date /% _
Type of Disposition
PlaceState
city 7._,q/d— D�
!me r Crema
Date
�
T.
(rev