TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER e: VITAL RECORDS
PART 500 ILLINOIS VITAL RECORDS CODE
SECTION 500.APPENDIX G DEATH RECORDS



Section 500.APPENDIX G   Death Records

 

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

 

STATE  OF  ILLINOIS                                                      PERMIT NO.__________

 

THIS PERMIT MUST ACCOMPANY BODY TO DESTINATIONORIGINAL           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

 

ON

 

, 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)