Raymond Beck' ° ° .r STATE OF ILLINOIS PERMIT
NO.
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PERMIT FOR DISPOSITION OF DEAD HUMAN BODY
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DECEASED— NAME FIRST MIDDLE LAST
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DATE OF DEATH
(MONTH, DAY, YEAR)
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AGEj L "ST .
OF DEATH COUNTY CITY, TOWN, TWP. OR ROAD DISTRICT NUMBER
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BIRTHDAY (YiS.)
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COOK 1 CHICAG®
(YES/N)F;
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DISPOSITION AUTHORIZED
CAUSE OF
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❑ HOLD' BODY BEYOND 72 HOURS
INTERMENT, ON (DATE) �
DEATH:4�1
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PLACE O " 1 'POSITION (NAME AND LOCATION OF CEMETERY, CREMATORY OR LABORATORY)
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9—CREMATION,
ON (DATE)
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❑ TRANSIT r-1DISINTERMENT
PLACE OF DISINTERMENT–(NAME AND LOCATION)
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SCIENTIFIC STUDY REINTERMENT
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THE REQUIRE 'OF OF ILLINOIS LAW HAVING. BEEN MET, THIS PERMIT TO DISPOSE: OFA DEAD HUMAN BODY. IS ISSUED TO.
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FUNERAL DIRECTOR;. ILL. LICENSE NO.
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ADDRESS:
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DATE: (SIGNED)
LOCAL REGISTRAR
CHICAGO BOARD OF HEALTH
REGISTRATION ADDRESS: 16.10 Richard J. Daley Center, Room 111 BY:
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DISTRICT NO. Concourse Level; Chicago 60502
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SEXTON'S ENDORSEMENT:
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o THE BODY ACCOMPANYING THIS PERMIT WAS RECEIVED AND WAS ANTERRED CREMATED
ON -T_T"� _r'�_, 19 IN z _T CEMETERY O RY— NAME
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LOCATED AT — —fit e" -a (SIGNED). -'r
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SEXTON
GRAVE OR VAULT: BLOCK 7' LOT GRAVE
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SEE OTHER SIDE
ILLINOIS DEPARTMENT OF PUBLIC HEALTH - SPRINGFIELD
vR 204 (P.O. 63287-30M-10/87)