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TEXAS STATE DEPARTMENT OF HEALTH PERMIT
BUREAU OF VITAL STATISTICS BURIAL-TRANSIT PERMIT NUMBER
Q. Date of death(month, day,and year) 3. Death due to yEs El
1. Full name of ased Ye / / communicable
PERSONAL ,.�// n �/ AJf 6 disease NON r
DATA ON �� /7 r/ state
4. Sex 5. Color or race 6. Age In years 7. Place of de th / (city o precinct no.) .a n (county) (state)
■ DECEASED '� H12 1 ) 1J - Cbs `1/-r�-ei 5 I �'C'"X'"'�.
Method of Burial Li Cremation El Place of burial (name of cameter or crematorium) (city or town) (state) ,
removal or n
disposal Removal k isinterment❑ disposal 5-..e.- bA , / "-') Fit' € P-
MANNER AND /
License number Business address
N f funeral irector / // 42//A JG �� /-�
rPLACEOF I f1`r:r . 43 x CD
DISPOSAL ome of embalmer(if none,write none) License number Business address
A certificate of death having been filed as required by the laws of Texas and all laws and regulations governing the preparation and
AUTHORIZA. disposal of dead bodies having been complied with, permission is hereby given to dispose of the body as identified above.
TION TO _—
'DISPOSE OF Signature of IocgJ�rtegl trop Distill (city o precinct no.)� (county) 'Date
—�BODY �_-, / !'�" ,, /,/rve !
::;° -, / Name o amatory
DISPOSITION [k r { '' ! _ _ ._ ..._.. _.
OF BODY Location ity or town)Y µ (county) [(,tafe)) y Name person in char..
i - ■j�e y t e�.∎.-
Cr�mated❑ w�4 —
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