Maynard, James DEPARTMENT OF PUBLIC HEALTH
VITAL STATISTICS UNIT *i - -
October 15, 1 6? No. 67 - 7898
Date Issued District of Columbia
PERMIT FOR DISPOSAL OF HUMAN REMAINS
Name of deceased James Ernest i aynard. Date of Death 10-13-67
Place of Death Vet er-any__Adri itr tion_a ±sritn?_Sex h°'•71e._ Color White.
Cause of Death -_-creber1. Vascular Accident Age 53
Funeral Director .. 'garner & Purimhrey Tnc License Number 611
Place of Disposal glen Fa11s New. York, Pineview Cemetery,_ Date 10-18-67
Method of Disposal: p Burial ❑ Cremation ❑ Anatomical X`A Transit
6 '" 4,10,-.1...--1 E , M.D.
Director-of Pubnc rteaitn
RETURN FROM PLACE OF DISPOSAL
Respectfully returned to the Director of Public Health, District of Columbia, in compliance wit the require-
ments of law.
Date of Disposal _- e __ __ ____ �1 p t
' ����--�/ Place of Dis oral __},,..-/
Zr�:_4---��-,_ :A� �-- <<..._
Section Lot No.
7
74; �gnature < -) > . __ _ pl -
Date / f _1_5 Official Title�._:'&/� ti- ':4;�1.L
(j
IMPORTANT
(1) This permit must accompany the body to the place of burial or cremation if in the District of Columbia, otherwise to the wharf, station or
other place from which shipment is made.
(2) When burial has taken place within the District of Columbia it is the duty of the superintendent or other person having charge of the
cemetery where the within described remains have been interred to return this permit to the Director of Public Health after having signed it and
entered thereon the name of the cemetery, date of burial, and information as to the exact location of the grave in which said body was interred.
(3) When cremation has taken place within the District of Columbia, it is the duty of the superintendent or other person having charge of the
cemetery where the within described remains have been cremated to return this permit to the Director of Public Health after having signed it and
entered thereon the name of the crematory and date of cremation of the remains.
(4) If the remains herein described are to be cremated or otherwise destroyed, this permit does not become valid and is not a legal protection
to the person cremating or destroying the same until it has been countersigned by the Coroner of the District of Columbia so as to authorize such
cremation or destruction.
(5) Any alteration in this permit must be made by the Department of Public Health and officially signed.
PH-322-40.2(185-PHVB rev.) 12M 9/85
1-171