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Harland L ClarkSTATE OF ILLINOIS PERMIT NO. Cc.t rtEl ,-.Oh PERMIT FOR DISPOSITIONE DECEASED— NAME FIR: MIDDLE L,�S T jSEX T: AGE —%LAST P7 -c- OE BIRTHDAY (YRS.) DISPOSITION y ❑ HOLD BODY BEYOND 72 HC 4401 z j INTERMENT, ON (DATE) = ❑ CREMATION, ON (DATE) O TRANSIT ¢ ❑ SCIENTIFIC STUDY y THE REQUIREMENTS OF ILLINOIS' W O DEATH: F=. chmidt O ADDRESS: X RY OR LABORATORY): p D DATE: 29, 19M m REGISTRATION w DISTRICT NO. d SEXTON'S ENDORSEMEN N HAVING BEEN MET, THIS PERMIT TO DISPOSE OF A DEAD HUMAN BODY IS ISSUED TO: ;r C I& FUNERAL DIRECTOR;. ILL. LICENSE NO.%;42 LOCATED AT s �a Home,Inc. � GRAVE OR VAULT: BLOCK_ Sm R14jam y in VR 204 (P.O. 10935 - 60M - 12178) STATE OF ILLINOIS PERMIT NO. PERMIT FOR DISPOSITIONE MIDDLE L,�S T jSEX DATE OF DEAT (MONTH, DAY, YEAR) I 4401 . ATH COUNTY CITY, T . OR ROA® ICT NUMBS ERAN O rES/NO) I n I Q U T H 0 R I Z E D CAUSE OF Z S DEATH: F=. '1 09n N PLACE OF DISPOSITlbAEIKIMMO RY OR LABORATORY): p Q ❑ DISINTERMENT PLACE OF DISINTE E ANd"L m " ❑ REINTERMENT 0 N HAVING BEEN MET, THIS PERMIT TO DISPOSE OF A DEAD HUMAN BODY IS ISSUED TO: m C I& FUNERAL DIRECTOR;. ILL. LICENSE NO.%;42 z Home,Inc. � Q Sm R14jam y in < o u V (SIGNED) ' n LOCAL REGISTRAR Q ADDRESS: BY: r THE BODY ACCOMPANYING THIS PERMIT WAS RECEIVED AND WAS INTERRED CREMATED IN4 CEMETERY OR CREMAJZ&Y— NAME a ,f 7 N { (SIGNED) SEXTON LOT GRAVE SEE OTHER SIDE ILLINOIS DEPARTMENT"OF PUBLIC HEALTH ® SPRINGFIELD