William L MillerFuneral Home First Assuming Custody of Bo
F7LjL
/1,3 K)'um& Me -
Nam eeW Address /�. I Phone
Name and Address of Funeral Home Handling Final & Disposition if other than Funeral Home Named Above o�pbid 11 1A
7M St - N
Permission is hereby granted to remove this body and upon compliance with the requirements of the laws of this state to dispose of the remains. If
disposal is by cremation or burial at sea, a certified copy of the death certificate and, when required by law, an authorization by the medical examiner
mustthM'p mit p5for /odWo
lsition.
PM JIL319-
Signature of Registrar or other authorized issuing officer Dke Issued Name and Address of Cemetery or Crematory
For Use Only By Coroner Issuing Permit
Was (or will) death (be) actively investigated? El Yes El No
DHEC Form 676 (Rev. 7/90)
AA
BURIAL ® REMOVAL — TRANSIT PERMIT
and
12 4 6 2 E_-)
SOUTH CAROLINA DEATH NOTIFICATION
PERMIT NUMBER
DEPT. OF HEALTH and ENV. CONTROL
k-5-44/
OFFICE OF VITAL RECORDS AND PUBLIC HEALTH STATISTICS
CA 4r
Death Certificate Attached El Yes El No
COUNTY
Name of Deceased
Date of Death
Hour of Death
Fetal Death
/-e i2p t1cl
P IZ 192
q,'6) 5
13 Yes 49qro
Place of Deatb_(Hospital or eet & Numperl,,_ city
VStr)q or Town
A'/w 4-5 /D
If Hospital Death
0 D.O.A.
POrn-Patient
/0 9
le, ri
0 Emer. Rm.
0 Out -Patient
CERTIFIER (Physician, Medical Examiner or Coroner who is to provide cause of 812r?!S
Autopsy
Was Case Refered To
death and certib, death certificate)
Joe/ 13. K
0 Yes No
Medical Examiner/
i
Coroner? 0 Yes No
Funeral Home First Assuming Custody of Bo
F7LjL
/1,3 K)'um& Me -
Nam eeW Address /�. I Phone
Name and Address of Funeral Home Handling Final & Disposition if other than Funeral Home Named Above o�pbid 11 1A
7M St - N
Permission is hereby granted to remove this body and upon compliance with the requirements of the laws of this state to dispose of the remains. If
disposal is by cremation or burial at sea, a certified copy of the death certificate and, when required by law, an authorization by the medical examiner
mustthM'p mit p5for /odWo
lsition.
PM JIL319-
Signature of Registrar or other authorized issuing officer Dke Issued Name and Address of Cemetery or Crematory
For Use Only By Coroner Issuing Permit
Was (or will) death (be) actively investigated? El Yes El No
DHEC Form 676 (Rev. 7/90)