Section 500.APPENDIX G Death Records

Section 500.ILLUSTRATION C Permit for Disposition of Dead Human Body

STATE OF ILLINOIS PERMIT NO.__________

ORIGINAL PERMIT FOR DISPOSITION OF DEAD HUMAN BODY

DECEASED – NAME

FIRST

MIDDLE

LAST

SEX

DATE OF DEATH

(MONTH, DAY, YEAR)

AGE – LAST

BIRTHDAY

(YRS.)

PLACE OF DEATH

COUNTY

CITY, TOWN, TWP. OR ROAD DISTRICT NUMBER

U.S. WAR VETERAN

(YES/NO)

DISPOSITION AUTHORIZED

CAUSE OF

DEATH:

□ HOLD BODY BEYOND 72 HOURS

□ INTERMENT, ON (DATE)

PLACE OF DISPOSITION (NAME AND LOCATION OF CEMETERY, CREMATORY OR LABORATORY)

□ CREMATION, ON (DATE)

□ TRANSIT

□ DISINTERMENT

PLACE OF DISINTERMENT (NAME AND LOCATION)

□ SCIENTIFIC STUDY

□ REINTERMENT

THE REQUIREMENTS OF ILLINOIS LAW HAVING BEEN MET, THIS PERMIT TO DISPOSE OF A DEAD HUMAN BODY IS ISSUED TO:

________________________________________________________, FUNERAL DIRECTOR;. ILL. LICENSE NO.___________________

ADDRESS:

DATE:___________________ (SIGNED)______________________________________________________________LOCAL REGISTRAR

REGISTRATION ADDRESS: BY:

DISTRICT NO.

SEXTON'S ENDORSEMENT:

THE BODY ACCOMPANYING THIS PERMIT WAS RECEIVED AND WAS: INTERRED/CREMATED

, 19

, IN

CEMETERY OR CREMATORY – NAME

LOCATED AT

(SIGNED)

SEXTON

GRAVE OR VAULT: BLOCK

LOT

GRAVE

SEE OTHER SIDE

VR 204 (P.O. X002570-35M-2/90) ILLINOIS DEPARTMENT OF PUBLIC HEALTH - SPRINGFIELD

(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)