Annis, Kelly70-ldhec
South Carolina Department of Health and Environmental Control 6ag
BURIAL - REWOVAL'- TRANSIT PERMIT
and _
DEATH NOTIFICATION 411432
COUNTY
Name of Deceased Date of Death - (cannot be unknown) Time of Death ❑ AM
❑ PM
❑ UNKNOWN
If Reportable Fetal Death (350+ grams), Provide Mother's Full Name
Place of Death (Facility Name or if not institution give Street and Number)
IF DEATH OCCURRED IN A HOSPITAL: IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
❑ Inpatient ❑ Emergency Room/Outpatient ❑ Hospice facility ❑ Nursing home/Long term care facility
❑ Decedent's home ❑ Other (Specify)
CERTIFIER (Name of Physician, Medical Examiner or Coroner who is to provide cause of death and certify death certificate.)
Address Phone
Autopsy ❑ Yes ❑ No
Was Case Referred To Medical Examiner / Coroner? Fl-Yes ❑ No
Funeral Home or Other Agent First Assuming Custody of Body r r
Name
Address Phone
I hearby certify that I have received the remains of the above individual.
Signature: �����--�--� Date: I? -1 D - 2D 1 q
Name, Address, and Phone Number of Funeral Home or Other Agent Handling Final Disposition if other than Named Above
Date Assumed Custody of Body
Signature
Permission is hereby granted to remove this body and upon compliance with the requirements of the laws of this state to dispose of the remains.
A certified copy of the death certificate, and when required by law, an authorization by the coroner or medical examiner must be attached to the
permit prior to disposition if disposal is by cremation or burial at sea. Neither a death certificate nor a report of fetal death is required to authorize
cremation of fetal remains.
Signature of Registrar or other authorized issuing officer Printed Name ; ' Date Issued
For Use Only By Coroner Issuing Permit Name and Address of Cemetery or Crematory
Was (or will) death (be) actively investigated? ❑ Yes ❑ No �r,, ,, Z U-VC, L,;
Date of Disposition Signature of S xton or Person in Chargel 11�'Q
DHEC-0649 (12/2016) t
Public Health Law Sec. 4145(2b) 012534
Receipt
Human remains of > /� /� = delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License # '� e_