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)