Kruger, Daniell DHEC South Carolina Department of Health and Environmental Control
 -'_ _ - 7. BURIAL - REMOVAL -TRANSIT PERMIT
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PROMOTE PROTECT PROSPER DEATH NOTIFICATION
DIVISION OF VITAL RECORDS ),-y�1, 166822
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Death Certificate Attached ❑ Yeso
Name of Deceased Date of Death Time of Death Reportable
S Fetal Death
/1,9"11 I //47-/-0A * 6' ❑ AM PM ❑ Yes ❑ No
Place of Death (Facility Name or i"nottion give Street and Number) City or Town Zip Code
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If Hospital Death: ❑ D.O.A. ❑ In-Patient ❑ Emer. Rm. ❑ Out-Patient
CERTIFIER(Name of Physician,Medical Examiner or Coroner who is to provide cause of death and certify death certificate.)
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Address ! t Phone
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Autopsy El Ye •s o Was Case Referred To Medical Examiner/Coroner?4s❑ No
Funeral Home or Other Agent First Assuming Custody of Body
Name
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Address Phone; / I/ t-1,4//),0'—
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Name and A dress of Funeral Home or Other Agent Handling Final Disposition if other than Named Above
Br� qa_.- Funecal Home, Inc.
24 Church St. , P.O. Box 500
Lake Luzerne, NY 12846
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. /'=-)
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Si ature of Registrar or other Rut o?ized issuing officer Date Issued
For Use Only By Coroner Issuing Permit Name and Address of Cemetery or Crematory
Was (or will)death (be) actively investigated? ❑ Yes Cl IVo
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Date of Disposition Signature of Sexton or Person in Charge p
3/17115 AZ /
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