Riley, Henry 9
PERMIT FOR FINAL DISPOSITION OF HUMAN REMAINS Cr""k7..vc- t
Name of Decedent Sex Date of Birth Date of Death
Henry B. Riley M 12-11-00 2-1-90
Place of Death—City or Town County Name of Informant
Knoxville Knox Fd Riley
Name of Funeral Director(or Person Acting as Such) Street & Number or Route
McCarty Mortuary, Inc. 3932 Forest Glen Dr.
Address of Funeral Director(or Person Acting as Such) City, State &Zip Code
4004 Holston Dr. , Knoxville, Tn. 37914 Knoxville, Tn. 37919
1 Charles F. Williams hereby apply fora permit
Application for the final disposition of the remains of the above named decedent. I agree to
for Permit abide by all laws and regulations of the Tennessee Department of Health and Environment and all other laws per-
taining to the pr arati , container, transportation, burial and/or cremation of same.The type permit needed is
checked bel . 2
n
Signature /6> Address
4004 Holston Dr. , Knoxville, Tn. 37914
TYPE OF PERMIT REQUESTED
(Check Boxes that are Applicable)
® Burial ❑ Disinterment
❑ Cremation ❑ Reinterment
❑ Transit ❑ Scientific Use
Burial Name and Address of Cemetery where Remains are to be Interred County
Pine View Cemetery - Glen Falls, N.Y.
Cremation Name and Address of Crematory where Remains are to be Cremated
Transit From To
Knoxville, Tn. Glen Falls, N.Y.
Disinterment Removed From(Name and Address of Cemetery)
Reinterment Place of Reinterment(Name and Address of Cemetery)
Scientific Use Name and Address of Facility Receiving Remains
Authorization of I certify that I have examined the remains of the above named and consent to the issuance
Physician or Medical of the Permit for Final Disposition.
Examiner
Signature of Attending Physician or Medical Examiner Address
Permit of This permit for the final disposition of the remains of the above named is granted for the purpose(s)
Local Register checked o , in accord nce with Ch pter 128 Section 18,of the Public Acts of 1977.
Signature of Local Registr . a:L€t, Address
Certification of I certify that the disposition of the remains of the above named was made in accordance with
Person in Charge this permit on 3-/y -70 at rinir- V1r-f.) Cc-Mc-.-/-c=if y1 (i,t�G it/S!3U1/
of Disposition Date Place
Signature
Address
PH-1687
VR 7178