Moon, Virginia ISEVir;.:9FIKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First • Midd Last i: ,ts,.I. j
S
•
.:::::......................._...........
Date of Death i Age i If Veteran of U.S me d .or.
...
6 - War or Dates
..... ...
Place of Death H
ital os Insti tution or
P
City,Town or Village € Street Address
C� Cause of Death ,, :."::.�-::::::::: : : :::._::: y�.:.:.:::. :.�.: : . ..... ::::: :.:.:::: ::: :.
lu
ry
l Medical Certifier Nam Ti e
s Address J
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Death Certificate Filed I/ District Number i Register Number
City,Town or Village . Xt.4.- ; k 6 o / ,iR A
Date U Cemet or Cremat
❑Burial
2/-ez -,--- ---{.4-s-1.-: ,,•
Address
Dapr/ation
Z Date Place Remove
o ❑ Removal and/or Held
h and/or Hold
Address
N
0: .......:.. P,... ..;.........y...,:....... ... ...... .................
o. Date • Point of.:......................:................:..:.:..:.....................:.:..:..:::............:..............................
Cl) Trans ortation b Shipment
CommonCarrier ............................................................................................................................................................................................
Destination
❑ Disinterment Date ' Cemetery Address
❑ Reinterment
Date Cemetery Address...................: ......:....:..:...........................:..::................,...........:.....
Permit Issued to Re
gistration Number
Name of Funeral Firm
«iiii: Address `f ::::::...:.::::::::::::
b ..)/ .)/‘- '4.-'4-•••-) -At' ' .A,,,,,4_,/st., )11/4-5.g..,/ /.. -.5.W„,c _
: : Name of Funeral Firm Making Disposition or to Whom
o Remains are Shipped, If Other than Above
Au
' Address
; >
Permission is hereby granted to dispose of the dead human remains described above as indicated.
iiiiiiig Date Issued 7 ›- Registrar of Vital Statistics (� `/ G t L, i /ti
(signature)
M:i:ii District Number Place // �l.Ll...) Z /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
•Z e o osition Date Dis
Lap /3/�7 Place of Disposition t, e r^ e r4, 4cJ/ Li rTi
2, (address)
>W'.
(section) (lot number) (grave number)
ca Name of Secton or Person in Charge of Premises —_:/v 4 .1 -✓• tC d S S -Ni/`,
la'z. print)
W Signature c�-�'17,. Title (fie r^�d LA / +t c 1, ,1-+'4e
DOH-1555(9/86)p 1 of 2(formerly VS-61)