Rolland W NelsonI
STATE OF IOWA
IOWA DEPARTMENT OF PUBLIC HEALTH
Bureau of Vital Records
BURIAL TRANSIT RERMIT
TYPE OR PRINT LEGIBLY. DO NOT USE ALL CAPITAL LETTERS
PART 1. DECEDENT INFORMATION
Name of Deceased Rolland W. Nelson
iddle)
(Last)
Date of Death 2 —4-04 Death Communicable? Yes
(Month) (Day) (Year)
(Suffix)
No x
Place of Death Des Moines Polk Iowa Mercy Hospice —Johnston
(City) (County) (State) (Street Address or Hospital)
PART 2. BURIAL INFORMATION
Burial x Cremation Donation Removal from State IOWA Other
_ (Specify)
Place of Disposition Blair Cemetery Location Blair Nebraska
(Name of Cemetery, Crematory, or other place) (City) (State)
PART 3. ISSUANCE INFORMATION
Permit Issued to: James D. Raddatz
(First) (Middle) (Last) (Suffix, if any)
Address 8201 Hickman Road Urbandale, Iowa 503
( treat)
Signature (In Ink)
(By signing, I attest to my right to make this transit requ
A Certificate of Death or Fetal Death has been filed in actor nc q
Permission is hereby granted to dis e
(State) (Zip Code)
Date02/07/2004
Vith Iowa Code, chapter 144.26 - 144.35.
of this body.
Permit Issued by: Caldwell Raddatz Funeral Home
(First) (Middle) (Last) (Suffix, if any)
Address
8201 Heckman Road Urbandale IA 50322
Signature (In Ink)
[Stye
signing, I atteft to y right to issue this permit)
(City)
(State)(Zip Code)
Date
PART 4. CODE OF IOWA INFORMATION.
A Burial Transit Permit is not issued for every death or fetal death, only as provided for under Iowa Code 144.32
144.32 Burial Transit Permit. If a person other than a funeral director, medical examiner, or emergency medical service
assumes custody of a dead body or fetus, the person shall secure a burial -transit permit. To be valid, the burial -transit
permit must be issued by the county medical examiner, a funeral director, or the county registrar of the county where the
certificate of death or fetal death was filed. The permit shall be obtained prior to the removal of the body or fetus from the
place of death and the permit shall accompany the body or fetus to the place of final disposition. To transfer a dead body or
fetus outside of this state, the funeral director who first assumes custody of the dead body or a fetus shall obtain a burial -
transit permit prior to the transfer. The permit shall accompany the dead body or fetus to the place of final disposition. A
dead body or fetus brought into this state for final disposition shall be accompanied by a burial -transit permit under the law
of the state in which the death occurred. A burial -transit permit shall not be issued to a person other than a funeral director
when the cause of death is or is suspected to be a communicable disease as defined by rule of the department.
588-0002 (07/1997) CPI -09750