Robert F HutchinsonIllinois Department of Public Health PERMIT FOR DISPOSITION
Division of Vital Records OF DEAD HUMAN BODY
D
DATEF DEATH -
9
�-'6
NAME OF DECEASED
PLACE OF DEATH (STREET OR INSTITUTION) CITY COUNTY
VETERAN
K'
-A- fYES EJ NO
PLACE OF DISPOSITION (NAME AND LOCATION OF CEMETERY, CREMATORY)
77 7k
A N
0 CREMATION TSHIP OUT OF STATE El CORONER OR MEDICAL EXAMINER
IF ANY OF THE ABOVE ITEMS ARE CHECKED, THIS PERMIT MUST BE SIGNED BY THE LOCAL REGISTRAR
PRIOR TO DISPOSAL OF THE BODY.
NAME AND ADDRESS OF PHYSICIAN WHO WILL SIGN DEATH CERTIFICATE
T
CENTONI
d
I CERTIFY "I HA$E CONTAGtED THEPIHYSICIAN AND HE/SHE WILL SIGN DEATH CERTIFICATE.
J TZ
DIRECTOR
SIGNED FUNERAL
FUNERAL
NOME NA 1,
A DADDRESS
4S
REGISTPAilI I
'o SIGNATURE DIST. NO.
'SLE DATE PERMIT SUED
REGISTRAR ADDRESS o i /.-,I
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VR-205 (1-95)
SEER VERSE SIDE FOR INSTRUCTI
PART 2