Willard, Sam Adam 411, South Carolina Department of Health and Environmental Control
TPdhec
BURIAL - REMOVAL -TRANSIT PERMIT LL....
and
DEATH NOTIFICATION
LEXINGTON 2023117662
COUNTY BRTP Number
Name of Deceased Date of Death- (Cannot be unknown) Time of Death
SAM ADAM WILLARD 04/16/2023 01:50 PM
If Reportable Fetal Death (350+grams), Provide Mother's Full Name
Place of Death (Facility Name or if not institution give Street and Number)
390 CRYSTAL SPRINGS ROAD LEXINGTON SC 29073
IF DEATH OCCURRED IN A HOSPITAL: IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
0 Inpatient 0 Emergency Room/Outpatient 0 Hospice facility 0 Nursing home/Long term care facility
0 Decedent's home ® Other(Specify) ROADWAY
CERTIFIER (Name of Physician,Medical Examiner or Coroner who is to provide cause of death and certify death certificate.)
MARGARET W.FISHER
Address Phone
117 DUFFIE DRIVE LEXINGTON SOUTH CAROLINA 29072 (—)--
Autopsy ® Yes 0 No Was Case Referred To Medical Examiner/Coroner? D Yes ❑ No 0 Unknown
Funeral Home or Other Agent First Assuming Custody of Body
Name SHIVES FH INC-TRENHOLM RD CHAPEL
Address Phone
7600 TRENHOLM EXT ROAD COLUMBIA SOUTH CAROLINA 29223 (803)754-6290
I hearby certify that I have received the remains of the above individual.
Signature: Date:
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.
Electronically signed by ATAYLOR ANDREW TAYLOR 04/18/2023
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 0 No
Date of Disposition Signature of Sexton or Person in Charge
DHEC-0649(12/2016) THIS COPY FOR FUNERAL HOME OR OTHER AGENT
Public Health Law Sec. 4145(2b) 012976
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
Willard
NAME Sam Adam Willard LF e:na
Lot Owner: Mark L. Willard
Lot# Undilla Ext. 6B Grave# 4
Case: Concrete
Died: 4 . 1 6 .2 3 Interred: 4.2 8.2 3
Funeral Home: Regan Denny Stafford
Cemetery: Pine View
WILLACM
Lot No. 6 B
Address 42 Mason St., Glens Fallas, N.Y. — Section No,
Owner Mark L. Willard Plot IInadi»a
Date 1/13/73
no Superficial ft. @ $2.00 per sq. ft.
Location Bounder' on the North by Mutant, Fast by Webb, Snuttt by Road, West by Path.
Corner Posts
Remarks
Deed No. (and changes) 1247
Payment Record Paid in full 1/13/7LSO HPI`q R
%,\) 1 - -CIZdrct,-1-‘4 `-1
3(6" s
Form No. 01
Record of Interments
5
k Z , ' I Birney R. Willard (11-15-20094, (4...': '----- ' ' . - '
Beatrice P. Willard ( 1/13/73) 6
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