Omer c MalletteBURIAL/TRANSIT/CREMATION PERMIT N° 6 9 2 9 6 1 U�
APPLICATION
A.t ..........
1. Full .name of deceased ..... � �• • • ' ' ' ' ' ' ' ' ,�
(City 6W., ....................... .t��• .. '.."........ , .. • (State)
2. Place of death ............ (County)
)
.....��........................................................
3, Was deceased ever in U.S. armed forces. (yes, no, or unknown) (If yes, give war or dates of service)
4. Date of death • • • • 5. Color 1 j
6 Age. .... 7. Sex.......
rJ .. ...... ......
8. Cause of death ...... $...."ire ;.6.
.
9. Attending Physician or Coroner
..........................
Ad ress
..........via.......... .
10. Method of disposition r a` (if transit)
,yurtal transit cremation,other�spemfy)
11. Cemetery or crematory ... �-�y�){� �` ,;� , , C ung
12. As required by law a certificate has bee,
iled with the ounty Regstr of ,"
13. Name and address of mortuary.I �''' �'
Personal signature of representative ............
PERMIT
14. A certificate having been
filedas required by the laws and regulations of this state s holdingy a funeral director permits
aska
funeral director's license, permission hereby granted to dispose he deceased as above stated, except that special permitsshall
be secured forremati n or disinterment. ...... da of........
.... y-�. ' ' ' ' ' ' ' ' ' ' ' 9.
[ 1
Dated at. ...`f . tL t"
�........ this....
Y
WHEN USED FOR CREMATION, THIS PERMIT MUS Bl- 17NED jUNT
REGISTRAR.
Signature.......... .::...�.,..
o r Deputy)
To be signed and dated by agent of transportation company when used as transit permit
)
Date
(
..........................................
15. .................................... (Date)
...............
(Signature of agent and name of company)
.....
• � � � (Destination)
....... ......
(Method of transportation rail, air, etc.)
Cemetery Authority or Funeral Director Shall Fill Out Space Below
17. Body was. ................ on ..... ............ 19 in _ _ ' etery, ' f'
(Buried, etc.) - • .
• , ,c . ... ,. .. �., ..... .
18. Place.. ' ' Signature....... (s �r funeral director)
(City) (County) (State)
nt is made in State of Ne6raska(orby the Funeral Director where there is no Sexton and returned by
This permit must be completed and signed by the Sexton where interme
the funeral director within 10 days to the county registrar, county of burial.
SEE OTHER SIDE BUREAU OF VITAL STATISTICS
STATE DEPARTMENT OF HEALTH
P.O.BOX 95007
Lincoln, Nebraska 66509-5007