Harold Christian JuulN
MISSOURI DEPARTMENT OF
`BUREAU OF •-•
OUT-OF-STATE DISPOSITION NOTIFICATION/AUTHORIZATION
This notification is to be used only when deemed necessary by Funeral Home Licensee.
The State of Missouri no longer requires the acquisition of a permit prior to disposition of a dead body, effective August 13,
1984. Authorization for disposition is acquired through notification of death to the Local Registrar in the county which the
death occurred.
Section 193.175, RSMo (1986)
1 HEREBY CERTIFY THAT NOTIFICATION OF DEATH FOR
DECEDENT HAROLD CHRISTIAN JUUL
WAS FILED WITH THE LOCAL REGISTRAR OF
COUNTY
DATE FILED BY LOCAL REGISTRAR (MONTH, DAY, YEAR)
2/4/06
POLK COUNTY MISSOURI ON
CEMETERY OR CREMATORY - NAME
BLAIR CEMETERY
LOCATION (CITY, STATE)
BLAIR, NEBRASKA
DATE (MONTH, DAY, YEAR)
2/8/06
SIGNATURE (FUNERAL HOME LICENSEE)
MO. LICENSE NUMBER
2794
-17_
MO 580-0727 (10-92) AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER - services provided onrndiscriminatory basis VS -302 (10-92)