Jose InclanTYPE
OR PRINT
IN
PERMANENT
BLACK INK
IF DEATH
OCCURRED IN
INSTITUTION
SEE HANDBOOK
REGARDING
COMPLETION OF
RESIDENCE ITEMS
STATE OF EVADA - DEPARTMENT OF HUMAN RESOURCES (�o
DIVI I OF HEALTH - SECTION OF VITAL STATISTICS �1
BURIAL -TRANSIT PERMIT F
LOCAL FILE NUMBER STATE FILE NUMBER
DECEASED -NAME First Middle Last - DATE OF DEATH (Month, Day, Year) COUNTY OF DEATH
2 .,, 3a.
CITY, TOWN OR LOCATION OF DEATH HOSPITAL �,r,. HER INSTITUTION -Name (If not either, give street and number) If Hosp. or Inst indicate DOA, OP/Enver. SEX
Rm. Inpatient (Specify)
3b. 3c. 3e. 4.
RACE-(e.g., White, Black, American Was Decedent of Hispanic Origin? Specify ❑ yes Ono If yes, AGE -Last UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH (Mo., Day; Yr.)
Indian, etc.) (Specify) specify Mexican, Cuban, Puerto Rican, etc. Birthday (Years) MOS DAYS HOURS MINS
5. 6. 7a. 7b. 7c. 8.
STATE OF BIRTH CITIZEN OF WHAT COUN- Decedent's Education. Specify highest MARRIED, NEVER MARRIED, SURVIVING SPOUSE (If wife, give maiden name)
(If not U.S.A., name country) TRY grade completed. WIDOWED, DIVORCED
9a. _ 9b. 10. (Specify). _ 12.^..
SOCIAL SECURITY NUMBER
FUNERAL DIRECTOR
USUAL OCCUPATION (Give Kind of Work Done During Most of
DEATH DUE TO COMMUNICABLE DISEASE
KIND OF BUSINESS OR INDUSTRY
Acting as Such)
LICENSE NUMBER
24c. YES C] NQ.[]=...
Working Life, Even if Retired)
20a.
13.
20c.
14a.
14b.
To the best of my knowledge, death occurred at the
RESIDENCE -STATE
COUNTY
STATING THE
CITY, TOWN, OR LOCATION
investigation, in my opinion death occurred
a
STREET AND NUMBER
INSIDE CITY LIMITS
at the time, date and place and due
to the cause(s) and manner stated.
nU
(Signature and Title)
(Specify Yes or No)
15a.
15b.
15c.
HOUR OF DEATH "
15d
15e
FATHER -NAME First
Middle Last
MOTHER -MAIDEN
NAME First Middle
Last
16. 17. !!
INFORMANT -NAME (Type or Print) MAILING ADDRESS (Street or R.F.D. No., City or Town, State, Zip)
18a. _ 18b. ,
BURIAL, CREMATION, REMOVAL, OTHER (Specify) CEMETERY OR CREMATORY -NAME LOCATION City or Town State
19a. 19b. 19c ..
FUNERAL DIRECTOR SIGNATURE
FUNERAL DIRECTOR
NAME AND ADDRESS OF FACILITY
DEATH DUE TO COMMUNICABLE DISEASE
(Or Person
Acting as Such)
LICENSE NUMBER
24c. YES C] NQ.[]=...
WHICH GAVE
20a.
20b.
20c.
-
Z 21 a.
To the best of my knowledge, death occurred at the
time, date and place and
STATING THE
22a. On the basis of examination and/or
investigation, in my opinion death occurred
a
due to the cause(s) stated.
I DUE TO, OR AS A CONSEQUENCE OF:
at the time, date and place and due
to the cause(s) and manner stated.
nU
(Signature and Title)
5 (Signature and Title)
�m
-a
DATE SIGNED (Mo., Day, Yr.)
HOUR OF DEATH "
m0 DATE SIGNED (Mo., Day, Yr.)
HOUR OF DEATH
E 7
E
O z
21 b.
21 c.
8 c 22b.
22c.
}
U_
NAME OF AT -FENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
mo
otj PRONOUNCED DEAD (Mo., Day, Yr.)
PRONOUNCED DEAD (Hour)
~w
~
v
21d.
22d. ON
22e. AT
NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MEDICAL
EXAMINER, OR CORONER). (Type or Print.)
LICENSE NUMBER
23a. .: ( ..
.:
23b.
REGISTRAR
DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
DEATH DUE TO COMMUNICABLE DISEASE
24a. (Signature)
246. JAN 10 2006
24c. YES C] NQ.[]=...
CONDITIONS
IF ANY
WHICH GAVE
RISE TO
IMMEDIATE
25. IMMEDIATE CAUSE ( TER ONLY O E C USE PE L E,
CAUSE
STATING THE
UNDERLYING
PART (a)
CAUSE LAST
I DUE TO, OR AS A CONSEQUENCE OF:
DUE TO, OR AS A CONSEQUENCE OF:
• Interval between onset and death
• Interval between onset and death
Interval between onset and death
' PART OTHER SIGNIFICANT CONDITIONS -Conditions contributing to death but not resulting in the underlying cause given in Part 1. AUTOPSY (Specify WAS CASE REFERRED TO
® II • s Yes or No) CORONER (Specify Yes or No)
Burd 26. 27
AUTHORITY FOF7� RTATION, REMOVAL, CREMATION OR OTHER DISPOSITION
Having complied with all rules and regulatigWArs@Oy NdAlWation of dead human bodies and upon receiving the signatures of the person who is to certify the
cause of death, the funeral director or personj�� ector, and the local registrar, permission is granted to dispose of this body. The burial -transit permit
must be signed below by the cemetery or cre t ' here there is no full time person in charge of the cemetery the funeral director may sign as sexton.
Upon completion the permit must be ret uraecLt� t�re death occurred or tor the funeral director.
i Cemetery�or CreCmatory)
Signature of person in charge
of the cemetery or crematory Date
BURIAL PERMIT'