Kemp, Darnell STATE BOARD OF HEALTH `t'
OFFICE OF VITAL STATISTICS C m y
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Permit No.
Name of Deceased Date of Death (month,day,year)
Darnell 0. Kemp, R-3 , Goldsboro, N. C. 12-,k-7 ,
Name and Address of Funeral Home Shumate Fune ral Home Method of Disposal Removal
601 E. Ash St. , Box 167 ( ) Burial ( ) Disinterment
Goldsboro, N. C. 27530 l ) Cremation ( ) Other
Name and Address of Attending Physician, Medical Examiner,or Coroner
Dr. Warren Parmelee, Wayne Co. Medical Examiner, Goldsboro, N. C.
A certificate of death having been filed, or the requirements of the lawsof this state having Date issued (month,day,year)
been complied with,permission is hereby granted to dispose of this body.
Signature of Local Registrar, Deputy,or Sub-registrar Address
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Name an Address of Cemetery or Cr atory
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Dat of Disposition Signature.° exton or Person i '
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FORM 9 T IS COPY TO BE GIVE?iiiii
N RAL DIRECTOR (SEE INSTRUCTIONS ON REVERSE SIDE).
Rev. 6/68
STATE BOARD OF HEALTH ",.,a; "
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OFFIF VITAL STATISTICS /Q _ ,/ 7
E. Permit No.
Name of Deceased Date of Death (month,day,;year)
Darnell 0. Kemp, R-3, Goldsboro, N. C. 12* -71
Name and Address of Funeral Home Shumate Funeral Home Method of Disposal Removal
601 E. Ash St. , Box 167 ( ) Burial ( 1 Disinterment
Goldsboro, N. C. 27530 ( ) Cremation ( ) Other
Name and Address of Attending Physician, Medical Examiner,or Coroner
Dr. Warren Parmelee, Wayne Co. Medical Examiner, Goldsboro, N. C.
A certificate of death having been filed, or the requirements of the laws of this state having Date issued (month,day,year)
been complied with,permission is hereby granted to dispose of this body.
Signature of Local Registrar, Deputy,or Sub-registrar Addres - z) Aid
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Name d Address of CemeteYCr a or
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D te of Disposition Signatur S ton or Person in Charge/
/..16 -X7VAr t 1., '
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Rev.6/ 8 9 HIS COPY TO BE GIVEN 0 FUNERAL IRECTOR (SEE INSTRUCTIONS ON REVERSE SIDE).