Mabb, Tracie STATE BOARD OF HEALTH t oSiatc of .Tnrtli Carolina OFFICE OF VITAL STATISTICS
BURIAL-TRANSIT PERMIT
PERMIT NO.
NAME OF DECEASED AGE SEX COLOR OR RACE
TM" lig T.. 1
91
PLACE OF DEATH (CITY. TOWN OR TOWNSHIP) (COUNTY) DATE OF DEATH (MONTH, DAY, YEAR)
its f.. SKVAL r a)»...I- +t�l LF_ '-. 0 as es- APRIL - 22 3.,
CAUSE OF DEATH f
METHOD OF DISPOSAL PLACE OF DISPOSITION (NAME AND ADDRESS OF CEMETERY OR CREMATORY)
El BURIAL D CREMATION . . h y._me
2 REMOVAL El °^§ as
(SPECIFY OTHER) ' i�
NAME OF FUNERAL ESTABLISHMENT BUSI t ESS ADD ESS C.
A certificate of death having been filed, or the requirements of the laws of this state having been complied with, permiss-
ion is hereby granted to dispose of this body.
NATURE REGIST - DATE
\ Z
DAT A DISPOSITION - SIGNATURE 0 i SEXTON OR PERSONPERSON,M CHAR
Fo_so= OOM_
FORM 9 F SEE INSTRUC IONS OTHER .- "
CERTIFICATE OF HEALTH DIRECTOR
(This certificate must be completed by the health director or health department if death was caused by anthrax,
cholera, diphtheria, glanders,leprosy, meningococcus meningitis, plague, poliomyelitis, psittacosis, smallpox, Europ-
ean typhus fever, and the body is to be shipped by common carrier. Otherwise this certificate is not required.)
Cause of death -_ __. The body of deceased was prepared
in accordance with the rules and regulations of the North Carolina State Board of Health.
Date _
Signature
(HEALTH DIRECTOR)
INSTRUCTIONS TO FUNERAL DIRECTOR
This permit must be endorsed by the sexton or person in charge of the burial place, and returned to the
Local Registrar of his district with in ten days. If there is no sexton or person in charge, the funeral director
or person acting as such shall sign as the person in charge, giving date of interment or disposal. Write across
face of permit the words, "No person in charge," and return to the Local Registrar of the district within ten days.
When the body is to be shipped by common carrier, the registrar is authorized to issue this permit in triplicate.
The original should be enclosed in a strong envelope attached to the shipping case. As a safeguard against the
loss in transit, one copy, so labeled, should be mailed to the funeral director at destination, or handed to him
by the escort traveling with the body. One copy is for the transportation agent. No separate transit permit is
required.
Before shipment by common carrier, the body must be embalmed; or if that is not practicable, it must be
enclosed in a tightly sealed casket or outer case.