Mary Agnes FarnbergT" A N S�zl T (-, 0, P, Y STATE OF ANZONA REGISTRAR'S
•, DEPARTMENT OF HEALTH SERVICES - VITAL RECORDS SECTION FILE NO. 2129
IAL -TRANSIT PERMIT
NAME OF, A. FIRST B. MIDDLE C. LAST SEX AGE RACE OR COLOR
IDENTIFICATION 1 1) . EC EAS -t D MARY AGNES FARNBERG JEMALE 3. 79 4. WHITE
DATE OF DEATHP
� LACE OF DEATH A. TOWN OR CITY B. COUN , T'
OF JUNE 2, 1980 6. TUCSON PIMA ARIZQNA—
DECEASED CAUSE OF (MUST BE COMPLETED IF BODY 15 SHIPPED OUT OF STATE, MOVED BY COMMERCPTL OARRIER, OR A DEATH FROM CERTAIN DISEASES)
DEATH
7, NATURAL CAUSES
❑ BURIAL/ OTHER FUNERAL HOME A-. NAME B. ST. ADDRESS C. CITY AND STATE
MANNER n CREMATION (SPECIFY) q.SWAN FUNERAL HOME. INC. 1335 S. SWAN
AND E] REMOVAL FUNERAL DIRE(AT SIGN1E JDATE SIGNED '
PLACE OF e. REMOVAL OF CRENS. A.2� �T RIL6-13-80
MA
PLACE OF BURIAL OR A. NAMSTREET A.. C. CITY AND STATE
DISPOSITION OTHER [DISPOSITION BLAIR CEMETERY u BLAIR, NEB. 68008
12.
13.IN ACCORDANCEWITH THE LAWS OF THIS STATE AND THE REGULATIONS OF THE STATE DEPARTMENT OFHEALTH PERTAINING TO DEATH CERTIFICATES
REGISTRAR'S AND TH`E,, H AN D L I NG OF DEAD HUMAN REMAINS, AUTHORIZATION 15 HEREBY GIVEN TO DISPOSE OF THIS BODY IN THE MANNER INDICATED.
AUTHORIZATION REGI SIT R,;�'R S SI GN T�'l RR DISTRICT SIGNED
FOR
DISPOSITION6-13-80
Z�2
BODY WAS:C.,Y OR A. N E T.Ej, FI -A -F RE.;C, CITY AND STATE
CR
EM TORY
DISPOSITION ❑BURIED 1%'6�'z
8.. S _ ", -_ tll�. �/--4-,
OF BODY [3CREMATED DATE OF DISPOSITION Q;ME ERY MANAGE R` -S SIGNATURE
(SPECIFY)
17.00THER - 19. 20,
STATE DATE RCV-D. IN STATE OFFICE rEGISTRAR'S SIGNATURE TITLE
REGISTRAR USE 21. A. 122 B.
VS -7 REV. 7-74 CEMETERY MGR.: MAIL TRANSIT COPY IN 10 DAYS TO VITAL RECORDS, P.O. BOX 3887
DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA 85030