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Richardson, Evelyn B • Cemetery Call Work Sheet Date: Funeral Home/ Monument Company: Moss- t"CaS 1 C-k Contact Name: 11 p 0b 0 °o o6 c Tel. #: 6l1; - o2©?o Fax #: AN& -Cggl+ Reason for call: )N rM KA EN T- ??G-?n?y ca Ji l t l l 1? w ??Y 'ccet vM oat t r-t , kr-?o Wr}-? a 1 f x;111 kX (') 11 is 0'u,t t `J Deceased Name: C-V(FL-YAI & klcl-I Aget-)?d Date of Birth: Date of Death 0210Q Block Lot 40 Space Owner of Plot:* t, V0 10 . b h tcf atdsL n *************************** ********************************************************************* Full Burial Urn Space f $30.00 Staking Fee - received on: A, 11' 'A Date of Burial: LP / 1..3 / 0 Time: 1'00 am/pm Disinterment: L The following authorization should be obtained prior to disinterment: 1.) A disinterment permit and burial/cremation transit permit 2.) Written authorization from the individual(s) who currently own the burial ridws V" " for the plot; and 3.) Written authorization from the individual(s) who would be permitted to autho\r?e bur al ?c4 Interment: (One fu// burial and one urn, or two urns per space)a b 01 Monument Being Placed: (No Fee for Staking of Monument) lN? vJ Atlanta Crematory Inc. 1040 A Main Street Stone Mountain, Georgia 30083 770-469-5577 Certificate of Cremation The undersigned funeral director of the duly licensed crematory certifies that the remains of Evelyn Harper have been cremated at Atlanta Crematory Inc., a crematory licensed by the State of Georgia Board of Funeral Service ("Board') and located in the City of Stone Mountain, Georgia. Furthermore, the undersigned certifies that the remains of Evelyn Harper were cremated in accordance with the Laws and Rules and Regulations of the Board on February 9, 2008 The undersigned Funeral Director also certifies that the following information was delivered by Andy Millsaps , a person duly author- ized to care for the remains of the deceased from Wages & Sons funeral home. Name of the deceased: Evelyn Harper Social Security Number: 265-14-8554 Date of Death: February 8. 2008 County Hall State: GA Serial Number(s) of any Prosthesis removed from the Deceased (if any) ; Type of Prosthesis Type of Prosthesis Serial Number Serial Number Finally, the undersigned certifies that he/she is the Funeral Director of the Crema- tory in charge of the final disposition of the deceased identified in accordance with O.C.G.A. `43-18-8(a)(1). Furthermore, the undersigned certifies that the remains are being released to Ginger Moore a person legally authorized to accept the remains. Sworn (or affirmed) before me, This 8th dayof February 2008 Notary My Commission Expires - Signature of Funeral Director Howell T. Scott PRINT NAME GA License # 4418 Georgia Department of Human Resources Vital Records Service PERMIT FOR THE DISPOSITION OF HUMAN REMAINS D/,;" -;? -d9-/!<61 PERMIT NUMBER k Name of Deceased HR er Date of Death 1 Fetal Death? p " Z - ?J - DC0 B 1. 2 3 Yes ? Place of Death (Hospi I or Street No.) OR Interment (Cemetery) City, Town or Location of Death OR Interment County of Death OR Interment ?A(,L kcr)Jat-e C wd-e- 4 j G 0 1 Sv'k (? 2 I-4AL-?. . 5. . Name of Certifying Physician, Coroner or Medical Examiner (Not Used For Disinterment/Reinterment) Certifier's Address (Not Used For Disinterment/Reinterment) --3 e r _t t I 1` ?° 7. IJ'? ??tTY 1 e? 8. S ?? ?rJO ?C?1f1t51/? (1 ?. ? ? 30??0I Funeral Home Name and Address ff "e<, 4 Scn S (3t)l r nt-+?- e Funeral Home Lic. No. 9. 0-- l aF?wrtoCev? 11 e ,o. I Saa Method of Disposition OR Date of Disposition OR 11 Disinterment/ E] Reinterment 200 ? . Cremation Donation El Other El Re moval From State ? Reinterment ? 12. `-' Name and Address of Disposition OR Reinterment Site I ?+ WQc SnA s l Yern?z bY-Ll Location of Disposition OR Reinterment Site (County, City or State) - , .11, -- o.--1-- I AiA?V-P-rv P_ih 11, 3 A 13. 1 -1- - -- I ?14. v?v--'1"Ati 11 I ? ,- - -- I 31-10-20.(a) The funeral director or person acting as such, or other person who first assumes custody of a dead body or fetus shall obtain a disposition permit prior to cremation or removal from the state of the body or fetus. A disposition permit may be required within the state by local authorities. Local Vital Records Registrar - Signature Q Date Signed G? ?j - B? ,,T1 16. 2- I-0O Sexton (or Person In Char - Signature Date Signed C? 18. z -? -O? Form 3934 (Rev. 8-91) FUNERAL DIRECTOR C (D ct r? (D (D n F-' F-' A) G (Q N O N C TI F" /? 6J..d O r- ru r U-1 a- LW O F' r O ?. _. W LJ-I M3 Ln ru Ln g. Ln Lrn i Ct) -n-u ca{" c xv r co >mEm gym= U)dO o c x= °n o< ?o O = H N- Fj C n 10 ?> r] e FJ O rt H- 0 (D rt rt A) w ?l Fi O .. m A? C7 1-h ft H- (D rt 0 N z ° r OD (D n W m w n Lo x cr J (D Ul K 00 K- P H- w w O ry A N C) LQ CD N O 1- hi I TJ " m Lr t? a R. N w r- rr w w (D ? p n X K Na N• 0 w a? ro (D ? s rn v A A a y- a ?- t ? 0 m 2 * O - o (D f w O ' < m \ O M- l O * N ? m z u N v ' ° * N m m F m * \] z m m A H- l V G o D LQ m - e y- F? 10 > m H a 1 x (/? m .?:b N O 0 W Z m T m O W O N N F" m O m n O oae - 00 c m °o -1 < m z Q m m p - o m ' , ` }rte O w • Cemetery Call Work Sheet Date: to / AS / 02 Funeral Home / Monument Company: ?t .{ GdhGI Contact Name: C /?nn Tel. #: ?qJ" otvl I Fax #: Reason for call: I..tccKu-rx-e" Deceased Name: E-velF). LdAa-PAY?- j D ate of Birth: J11 Date of Death • Block A Lot ? Space Ll Owner of Plot: Interment: (One full burial and one urn, or two urns per space) Full Burial Urn Space $30.00 Staking Fee - received on: -/-/. Date of Burial: Time: am/pm Disinterment: The following authorization should be obtained prior to disinterment: 1.) A disinterment permit and burial/cremation transit permit 2.) Written authorization from the individual(s) who currently own the burial rights for the plot; and 3.) Written authorization from the individual(s) who would be permitted to authorize burial Monument Being Placed: (No Fee for Staking of Monument) I dt kq? CEMETERY BURIAL INFORMATION BY BLOCK/LOT/SPACE BLOCK : 9 LOT: 48 DECEASED NAME: STANLEY BATES BLOCK: 9 LOT: 48 SPACE: 1 BURIALTYPE: FULL BORN: 01 / 01 / 1909 DIED: 01 / 01 / 1948 INTERRED: 01 / 01 / 1948 INTERMENT NOTES: DECEASED NAME: EVELYN RICHARDSON BLOCK: 9 LOT: 48 SPACE: 2 BURIALTYPE: URN BORN: 12 / 29 / 1911 DIED: 02 / 08 / 2008 INTERRED: 06 / 13 / 2008 INTERMENT NOTES: MOSS FEASTER - JERRY, FUNERAL DIRECTOR DECEASED NAME: LOUIS PASCAUD BLOCK: 9 LOT: 48 SPACE: 3 BURIALTYPE: FULL BORN: 01 / 01 / 1881 DIED: 01 / 01 / 1948 INTERRED: 01 / 01 / 1948 INTERMENT NOTES: ****END OF BLOCK : 9 LOT: 48 **** I-] • Page 47 of 106