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VITAL RECORDS SECTION
IOWA STATE DEPARTMENT OF HEALTH
BURIAL-TRANSITPERMIT
ante
Full Name of Deceased----------t--------V------ L --------- Diels®n---------------------------------------------
Place of Death ---------------- S_a c------C--ity----------------------Sa C ------------------- I owa.
(Town or City) (County) (State)
Date of Death --------- ! -q1 9_____________y 19 $ Color k ____ Sex-- k ____ Age --__ 6— -_
Cause of Death ........ @n ing;-non–cOIClIiTl niCab e
----------------------------------------------------------
-_-_------
Method ofDisposal ----- r _ii ��°tate® ®burial
--------------------------------------------------------- Y --------
(Burial, Cremation, Transportation, etc.) (Cemetery or Crematory)
Town -Omaha....................... county ...... Dolqs--------------- State_ pbra s a
--------------
A Certificate of death having been filed as required by laws of this state, permission is hereby given to
Funeral Director:
------Arlan _E o--Otteman--------------- Address --- gt 4_ Mair ---Sac Ci��r6
(Name)
to dispose of body of said deceased as above stated.
Signature----------------------------------------------------
(Registrar)
Date-------
July -�-°----------- 19_82 Address----S� C -C ity r I ®ws-----------Sac County
(City or Town and County)
--------------
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SPACE BELOW
Bodywas-------------------------- on-------------------------- 19--- in --------------------------
(Whether Cremated, Buried, Etc.) (Cemetery or Crematory)
Located at-------------------------------- Signature ----------------------------------------------------
SEE OTHER SIDE I (Sexton or Person in Charge)
This permit must be endorsed by the sexton (or by the Funeral Director where there is no sexton) and
returned to the registrar within 10 days. Form V. S. No. 9
SHD-009-3/79