Reynolds, Helen tt Sb3
50.,
CENTRAL DISTRICT:St. g TIDEWATER DISTRICT:
400 East Richmond,Virginia 23219-3694 COMMONWEALTH OF VIRQI �IA 830 South Norfolk,Vi ginia123500
(804)786-3174 (757)683-8366
800-447-1706 800-395-7030
FAX(804)371-8595 Department of Health FAX(757)683-2589
WESTERN DISTRICT: Office of the Chief Medical Examiner NORTHERN VA DISTRICT:
6600 Northside High School Road 10850 Pyramid Place Suite 121
Roanoke,Virginia 24019 Manassas,Virginia 20110
(540)561-6615 (703)530-2600
800-862-8312 (703)530-0510
FAX(540)561-6619
CREMATION OR BURIAL AT SEA CERTIFICATE
I hereby certify that onf P -1 d I viewed the body of 1...k 1 a
Date
8.3 Tit F who died on I \ - + I 1 at S2- &1& O l 1 11ZSItL/
Age Race Sex Date Street and No.or Rural Route
and made personal inquiry into the cause and manner of death of said
City or County
decedent.Upon such view and inquiry it is my opinion that no further examination or judicial inquiry concerning the death is necessary.
---) Medical Examiner's Case: Yes ❑ No
•
Cause of Death: e t r (_6 ; - .!G-,-'" c...4.^- -r }.- 1.- erx--r_e_..o---
6
Manner of Death:
Permission is herewith given to C Am_p 0pa( 7
• Name of Person Applying for Certificate
1\b/X jj NI t to: Xcremate
__.____ ❑ bury at sea
)1. /\24, 144
Si9i/
iature of Medical Examiner
.t
/ /t ; .
A Street and Number or Rural Route
?cc 4 Vet.
City or Town
/7 ,-.7 yy ("41 45 e-ei tr 71' -e le_,,
Date Signed Ci or County of Medical Examiner's Jurisdiction
NOTE:Person applying for this certificate shall deliver to the signing Medical Examiner the fee established pursuant to§32.1-284,Code of Virginia.
Deliver the original certificate(white)to the person applying for it along with the(canary)copy for the crematory,retaining one(gold)copy
for your own use and sending the other(pink)to the District Office.
White-Funeral Home
Canary-Crematory
Pink-District Office
CME FORM No.5-Revised 2/02
Gold-Medical Examiner