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 D Coroner's or Medical Examiner's Permit to Cremate a Dead Human Body

 

 

STATE OF ILLINOIS

Permit No.

 

COUNTY OF

 

Date Issued

/ /

 

MEDICAL EXAMINER'S/CORONER'S PERMIT TO CREMATE A DEAD BODY

 

Full Name of Decedent

 

Decedent's Address

 

Date of Death

 

Place of Death

 

Cause of Death

 

 

 

Cause of Death Certified by

 

Permission to cremate the body of this decedent at

 

 

 

(Name and address of Crematory)

 

has been requested by

 

(Name and address of Funeral Home)

 

 

 

 

Funeral Director's Illinois License No.

 

 

(Signature of funeral director)

 

 

 

 

 

Being sufficiently informed as to the causes and circumstances of the death of the above described decedent, permission is hereby granted to cremate the body as requested.

 

Date_____________________ (Signed)_____________________________, Medical Examiner / Coroner

 

(MEDICAL EXAMINER CORONER WHITE) (CREMATORIUM CANARY) (REGISTRAR PINK) (FUNERAL DIRECTOR GOLD)

 

VR-204.1 (8/89r)

 

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