Hazel Arlene WaughSTATE OF ILLINOIS
CEMETERY RECQRD PERMIT FOR DISPOSITION OF DUD HUMAN BODY
DECEASED— NAME FIRST MIDDLE LAST SEX IDATI
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AGE — LAST IPLACE OF DEATH COUNTY (CITY, TOWN; TWP. OR ROAD DISTRICT NUMei
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PERMIT NO.
DEATH (MONTH, DAY, YEAR)
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DISPOSITION AUTHORIZED CAUSE OF QZ
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[I HOLD BODY BEYOND 72 HOURS DEATH:
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INTERMENT, ON (DATE) x�g "' PLACE OF DISPOSITION (NAME AND LOCATION OF CEMETERY, CREMATORY OR LABORATORY) p
❑ CREMATION, ON (DATE) y O
DISINTERMENT PLACE f
��TRANSIT ❑ OF DISINTERMENT (NAME AND `LOCATION) ~
❑ SCIENTIFIC' STUDY ❑ REINTERMENT 0
THE£;REOUIREMENTS OF ILLINOIS, LAW HAVING BEEN MET, THIS PERMIT TO DISPOSE OF A DEAD HUMAN BODY IS ISSUED TO: m
FUNERAL DIRECTOR;. ILL. LICENSE NO. CL`
ADDRESS
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DATE: (SIGNED) OCAREGISTRAR Q
REGISTRATION ADDRESS:~
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DISTRICT NO. > `
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SEXTON'S ENDORSEMENT:
THE BODY ACCOMPANYING THIS PERMIT WAS RECEIVED AND WAS; INTERRED/CREMATED C
ON 14
-IN F` CEMETERY OR CREMATORY —NAME' d -
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LOCATED AT ,.n,I . , r :_.� (SIGNED)
SEXTON _
GRAVE OR VAULT: BLOCK LOT GRAVE
SEE OTHER SIDE
P.O. #PRT3052220-25M-11/98)' ILLINOIS DEPARTMENT OF PUBLIC HEALTH = SPRINGFIELD -