Ill. Admin. Code tit. 77, § 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

(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)