Bullock, Raymond IVIMMIrlrl STATE BOARD Ole HEALTH
Burial Permit No.
BURIAL-TRANSIT PERMIT
Full name of deceased '70,Vmr] D vE7KEP PLILLOD4,
p Place of death LEIng PPach HE.-1-r 7-1,2.9i, Mississ',ppi
t
(Cityj
--)i, , (Couuty)
"fllU (Stawn
• Date of death Decemb:r 27, 19 ' Color Li 7' 1;e Sex Age
I Method of disposal T r E- ri`2')P nrtt-1_ 77 f7i-r F]wril Pinp YieW CeMRtUrV
(Whether burial, cremation, transportation, storage. etc.) (Cemetery or Crematory)
County Glens Falls State PThu, vork
;
i A certificate of death having been filed as required by the laws of this State, permission is hereby given
? to L9ns, Funr2rpl Hompi Inn. Address nulfpoft , Mississippi
L (Funeral Director or person acting as such)
I to dispos lf body of said d eased as above Jfted. j
> 71:
I Dated a ,- • - 7 , this. 2E1th day of Do,x ,Thpr 19
I ....., i (Registrar's ress) U :,/_
_..., ,_(9i_ ' _4.2_27:A__,,--,
I Registrar of -- Signature - -..,`" ,..
1 (Registrar)
— -
CEIMETERY. OR CREMATORY AUTHORITY SHM4I FILL OUT SPACE BELOW
Body was ,, -1--<-4.--e-- 1 on ,z .:-.Z-, - 3/ 197'42n. •(:--- - - i -"Le- -1-"4-1---
Place /IP ( whet cremated, b tored, etc.) c
--------
:747NSta s_ 4,- uried.; n- gnatur 1 r (s o4/Or person in charge)
! /
This permit must be endorsed by the Sexton (or by the Funeral Director where there is no sexton) and re-
turned within 10 days to the Registrar of the district in which the burial takes place.
Form No. 530