Glen William GreenVITAL RECORDS SECTION IOWA STATE DEPARTMENT OF HEALTH
BURIAL RANSIT PERMITz
0
GLEN IL IAM GREEN -_-__--_-_-_
HFull Name of Deceased-------------------- -- '-------------'-------- -
H Missouri V_lley_ Harrison Iowa r
Place of Death-------------- -------------- ------------
----- ----------------
(State)
(Town or
(County) --- (State) 56
w g� White Male
A Date of Death------------ January 12 __ 19_8 7 Color----- i t e_- Sex ------ - Age----------
® Metastases to live- ` Carcinoma colon ______________________________
H Cause of Death_________________ --------B l a l T C g m e t -r
------------ ----------------------
Method of Disposal_____ (Burial,
______________ ion, etc.) ------ (Cemetery or Crematory)
� (Burial, Cremation, Transportation, etc.) N e b r a s k a
Washington -- -- State--------------------
TownBlairCoun ---------------------------------�'------------------------
A Certificate of death having been filed as required by laws of this state, permission is hereby given to
Funeral Director: Phi 1 H W o o d b i n e I o w a
----------------_ H. F O _ U t s---------- Addr-----------------� -----------------------------
14
(Name)
® to dispose of body of said deceased as above stated.
Signature_ (Registr ------------------
)
----------------------------'
H Date----------------------------- 19____ Address_____--_----- (city or Town an County)
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SPACE BELOW
H Buried Januar 15________ 19_87, inBlair Cemetery
Body was-------------------------- on------- --y --- (Cemetery or Crematory)
(Whether Cremated, Buried, Etc.)
Blair Nebraska _ Signature ----------------------------------------------------
[xi Located at ---(Sexton or Person in Charge)
SEE OTHER SIDE
This permit must be endorsed by the sexton (or by the Funeral Director where there is no sexton) and
H returned to the registrar within 10 days. Form V. S. No. 9
-- $HD -009-3/79