Clute, Elizabeth C?/23/ „1$ FRL 9Edg PAX 18006132228 C350if 12100110t3
PERMIT FOR DISPOSITION OF HUMAN REMAINS ' FORM 3934(REVISED 12/2017)
PRINT OR TYPE ALL INF:ORMATiON LEGIBLY AND CORRECTLY BELOW.
Pursuant to 511-1-3-,23(4)A disposition permit shall not be issued until the cause of death has been certified by a
person authorind to do so under OPH Rule 511-1-3-.i,9(9);authorization given by the decedent's attending
physician;or with regard to a body subject to(nqulry under Title 45,Chapter 16,Article 2, until the county coroner
or medical examiner has given approval for disposition.
Sectitlift Tttrittll°RED"INFORIV1ATION' =' ```
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PF,NM{T NUMO�E7P T 1 I 1 t3 MA DCATI11 Yes PM No draoy9FOr TN OR INTERMENT
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r'IA E OM;Ile: M..1,Si1S'(ET NO,oft tY5t11MtN I IEtMETFPY{ CI Y.TOWN,Oq LOCNNDN Or OKATH On Euunrr
1091 Lombardy Way Jo esboro Clayton
"NAMGOr cliff IFYINC AHYS(_IAAACifleNlA•ORMEbICAL EXAMMER INOT USED MA'".-.. CERTIFlos's AOnirss INOT USE O ranoisINTrTTNMENT CRRt{NYF.,MENT)
�SINTE M[NTon IVTEAMEM
sou ern race �iospice 384 Racetrack Flood McDonough, GA
airport ortualry Shipping IIgigD' iTiTt,— Mtentral Avi veaz�rerEba 30354
METSUbot t7IsPn5ITICN _
GI Cremation D DlsintermentJReinterment
U Donation Evil Removal from State 2J2312018
b Other IA Date of Disposition OR Reinterment
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ota.'f°iiensTa1iNs;err eteryl`Uueei)st uly, 'Y
:Section2t SIGNATURES • . _ ..
Attesta on f r Cou istrar or Deputy Registrar
I, hereby attest that i have obtained assurance front the
a ding physician, asso late physician,or the chief medical officer of the institution In which the death occurred
that the death is from natural causes and that the phycician will assume responsibility for certifying the cause of
death or fetal death;or,that I have notified the coroner or medical examiner if the cause comes within his or her
jurisdiction or,if the physician cannot certify the cause'of death,obtained assurance frorn the coroner or medical
examiner that he or she will assume responsibility fur certifying the cause of death and the coroner or medical
examiner has given approval for disposition including cremation,donation,or transit across state lines.Or,I am
signing and issuing this disposition permit,based on a disinter/reinter written application signed jointly biy the
person who is in charge of the disinterment. Furthermore,4 am signing and issuing this disposition permit,to the
best of my knowledge,and if I knowingly provide false information on this disposition permit,I understand I am
subject to a fine or imprisonment,or both, under Title 31.10,31 and may be reported to the regulatory board
governing my license. •
,
DOW r)N ISTkAxori.fP YRlaI5rnAR DO(tMONTN,bAY.AGYEAN
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PADFESS OMS. i.1 e _} 8hAt I AG:SNI tam Au OCy`SS of A4G}TMfl DEMO;;ikors:LNAA
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Jonesboro,GA.30236
PLEASE ADDft SS AU.CORRESPONDENCE TO THE ADDRESS BELOW.
STATE OFFICE OF VITAL RECORDS I 1 b0 PHOENIX BLVD.SUITE 100, ATLANTA, i3 30349 I PHONE
404.679.170z
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