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 E Application for Disinterment Reinterment Permit

 

STATE OF ILLINOIS

DEPARTMENT OF PUBLIC HEALTH OFFICE OF VITAL RECORDS SPRINGFIELD 62761

 

APPLICATION FOR DISINTERMENT REINTERMENT PERMIT

 

(Must be presented to the Local Registrar of the Registration District in which the disinterment is to be made.)

 

I hereby request that a Disinterment Reinterment Permit be issued to

 

 

(Name of funeral director or person acting as such)

whose full address is

 

,

 

,

 

 

(Street Name and Number)

(City or village)

(State)

to disinter and reinter or remove the body of

 

 

(Name of Deceased)

who died of

 

 

on the

 

day of

 

,

19

 

,

at

 

,

 

 

 

(City, Village, Township or Road District)

(State)

from the

 

Cemetery, at

 

,

 

County, Illinois

 

(Name of Cemetery)

(City, Village, Township or Road District)

 

to the

 

Cemetery (Crematory) at

 

,

 

 

(Name of Cemetery or crematory)

(City, Village, Township or Road District)

(State)

It is understood that this disinterment is to be made in conformity with the rules and regulations of the Illinois Department of Public Health and any local cemetery regulations.

 

(Signed)

 

Full address

 

,

 

,

 

 

Applicant's relationship to deceased

 

 

Date

 

 

 

 

 

TO BE FILLED IN BY LOCAL REGISTRAR:

 

Disinterment Reinterment Permit Number

 

 

Date Issued

 

, 19

 

 

 

Local Registrar

 

 

Registration District Number

 

 

 

VR-207 (2/72r) This application is to be filed and preserved by registrar issuing permit.

 

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