Harland Clark JrA
Wiry "s Department of PuNic Health PERMIT FOR DiSposiTlOt4,,
Division of Vital Records OF DEAD HUMAN BODy
NAME OF DECEASED DATE OF DEATH
PLACE OF DEATH (STREET OR INSTITUTION) CITY COUNTY VETERAN
❑ YES 0,_ NO
PLACE OF DISPOSITION (NAME AND LOCATION OF CEMETERY, CREMATORY)
❑CREMATION ❑ SHIP OUT OF STATE ❑ CORONER OR MEDICAL EXAMINER
I
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
I CERTIFY I HAV€ NTA -ED THE I�14YSICIAN AND HEFSFIE WILL SIGN DEATH CERTIF1CATE.
a
SIGNED s. FUNERAL 178AE
FUNERAL 'HOME NAME AND ADDRESS
RE ISTRAR SI UFillL D DA R741t
e- rR
REGIS A D ESS
VR -205 (1-95) (SEE F VERSE SIDE FOR INS i RUCTI S)
ur
PART 2