Elmer Levi EngenBUTAL/TRANSIT/CREMATION PERMIT
APPLICATION N° 674730
I
I. Full name of deceased _ UUI ti
2. Place of death ....... ..': �"`
(Oityj ......... ,�qa? ......... _ .... rw.. ( u .... (State) ..
Co nt State
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 tip .. t � . 5. Color CJ .). ,"F. � . (. ................ 6. Age ..........7. Sex.Chg,
�t l .
8. Cause of death ....TUl: ".�C
9. Attending Physician or C ner t- g1 d Address .1 ff'... , sb . , ......
10. Method of disposition .l E '(� ............................via......,...............................
(burial, transit, cremation other specify) (if tran's'it)* .....
11. Cemetery or crematory # ( 1 � � C .. . , . , . , . ... . .
12. As required by law a certificate has been filed w tbi the County Registrar of County,
t t
13. Name and address of mortuary. t.t .; �s r l (,.� �� K C'� t� L
Personal signature of representative .... . .... ....
PERMIT
14. A certificate of death having been filed as required by the laws and regulations of this state by a funeral director holding a Nebraska
funeral director's license, permission is hereby granted to dispose of the deceased as above stated, except that special permits shall
be secured for cremation or disinterment.
Dated at ....................................... this............... day of ............... ..... , 19..........
WHEN USED FOR CREMATION, THIS PERMIT MILS1 BE SIGNED BY COUNTY REGISTRAR.
Signature.............................................................
(County Registrar or Deputy) 1
To be signed and dated by agent of transportation company when used as transit permit
15 . ........................................................
(Signature of agent and name of company) (Date)
16 . ........................................................
(Method of transportation —rail, air, etc.) ....(Destination]
Cemetery Authority or Funeral ]Director Shall Fill Out Space Below
17. Body was ................................ on................................ , 19 ........ in.....................
(Buried, etc.)
(Cemetery, etc)
18. Place...................................................Signature....................................
(City) (County) (State) (Sexton or funeral director)
This permit must be completed and signed by the Sexton where interment 'is made in State of Nebraska (or by the Funeral Director where there is no Sexton) and returned by
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 68509-5007
N" 674730 0
BURIAL/TRANSIT/CREMATION
PERMIT
Oy
om
ro
t�
a �
n
w Z
Q b
® tz
o ,c
n�
m �
� yro
w Z
•
o
� o �
0 0 o
C7
G
m m w
M n
CDC,
n
$ -
-
- -
Oy
om
ro
t�
a �
n
w Z
Q b
® tz
o ,c
n�
m �
� yro
w Z