Mellon, Matthew DHEC South Carolina Department of Health and Environmental Control
� BURIAL REMOVAL -TRANSIT PERMITand
PROMOTE PROTECT PROSPER DEATH NOTIFICATION DIVISION OF VITAL RECORDS (IC', 123891
COUNTY
Death Certificate Attached ❑ Yes ❑ No
Name of Deceased Date of Death Time of Death Reportable
la Wit/4.-{..,) /`}-) / Q �_ � _I � (� ��. C�.� Fetal Death
f f 2 �l ❑ AM C-Prv1 ❑ Yes RH
Place of Death(Facility Name or if not institution give Street and Number) City or Town Zip Code
17 &i�t >-CA... A✓60/e. /€ - i? 1 9']_ 2
If Hospital Death: ❑ D.O.A. ❑ In-Patient ❑ Emer. Rm. ❑ Out-Patient
CERTIFIER-(Name-ofPhysielan,Medical Exemineror Coroner whe is-to provide cause of death anc#certify-death-certificate.)
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Address Phone
7 S (rat �'�t "✓od/ / '- '5- 1S
Autopsy ❑ Yes No Was Case Referred To Medical Examiner I Coroner? ❑ Yes Diklo
Funeral Home or Other Agent First Assuming Custody of Body
Name
C , v y
Address Phone
Name and Address of Funeral Home or Other Agent Handling Final Disposition if other than Named Above
. C r` ...
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Permission is hereby granted to remove his 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.
( c /Z/ 1. 2 2- /V
ure,cif egistrar or other authorized i suing 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 ❑ No
PaPEttred CWAfrrPitinNi /1 COtAitke. 60131/ czof
Date of Disposition Signature_of Sextpn,Qr Person in Charge
a/sl1(1 44
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DHEC-0649(04/2013)
THIS COPY FOR FUNERAL HOME OR OTHER AGENT