Leo Frances SullyOHIO DEPARTMENT OF HEALTH
DIVISION OF VITAL STATISTICS
Form VS -14 (R 12/61) ®*<
NAME OF DECEASED
PERSONAL
DATA ON
SEX AGE
DECEASED
CAUSE OF DEATH
MANNER AND
URIAL
PLACE OF
DISPOSAL
NAME OF CEMETERY
A SATISFACTORY CERT
OF THIS STATE, PERMIT
AUTHOR-
IZATION TO
DISPOSE OF
FUNERAL
DIRECTOR
BODY
I ►]l�L'fl
4 OF
h `J�
❑ CREMATION
r
OF DEATH OR PROVISIONAL
TO DISPOSE OF THE BODY AS
SIGNATF REGISTRAR
This permit must etained by superintendent or
PERMIT
❑ OTHER/ tee_
DEAT14 HAVING BEEN FIL
PERMIT NO. _
DATE OF DEATH
v
ECIFY
COUNTY
DICATED ABOVE, IS HEREBY GIVEN TO;-- "C uiml
t;
ADDRESS
REGIST13�rJ�ON DISTRICT NO. I DATE OF ISSUE �
in charge of cemetery for a period of (5) fiv years