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North Carolina State Fireman's Association 3 <br /> P.O.Boa 188 <br /> Farmvihe,NC 27878 <br /> 800353-0733 <br /> 2001/2002 <br /> ANNUAL CERTIFICATION OF filth N <br /> North Carotive General Statute 58-6645 requires that all wished Fie departments submit a complete roster of <br /> its eligible transit initially. This certified list determines etigibJity,for the$15,000 Dne-of-0uty death <br /> beret as well as eligib0ity for Pension Fund credit. Failure to accurately and promptly,report this <br /> information is violation of G.S.58-86-25 and ll autamatlosay r esult in a loss m reduction of benefits <br /> REPORT BY FIRE DEP 1RTaTEN7 CRBSF <br /> As Fire Department Clicf,I have determined that he anacbed rather is a valid and accurate ist of all eligible <br /> Wemm,within the daErmunt cmnadend la North Carolina(owcal Statute 58-86-25. <br /> Fame ofFue Deoaim mt through County Fire Marshal's office <br /> Fire Department\lailmg Address p-o. Box 8161 <br /> City Hillsborough State MC lip Code 27278 <br /> Name cf Fir e Chief Milm Tapp - Fire Marshal <br /> -� t ' (Isfasep�arb7t) <br /> Signature of rims,chief— vwe <br /> Date December 10, 2001 Daytime Telephone_ 919 B6B-2n50 <br /> county orange <br /> CERTIFICATION BY GOVERNING BODY <br /> Pursumetto G.S. 59-8F 25,the sniveling body afar department operated by 6)a charity is the comy board <br /> (n) a city h a sciatic, my district chard, (v) o <br /> 1� carrots corporation,whether profit or nonprofit is�hc wrporazton's board of directors and(v)any other entity is that <br /> urup designated by the board Thetefnm in our scarcity as thcgovemht body of the avow mumd fro <br /> depamnet,we certify and find that the attached water us a rWtd use accurme fist of ell e1i d elm in <br /> accordanm with 0.6. 58-86-25. <br /> Name of Governing Body Orange ,County Board of County Coss <br /> Name of Governing Body Official Barry Jambs <br /> (Please Pont or type) <br /> Authonzed Signature __ . IrIE Chair Board of Commissioners <br /> Date Ian,arc, ins con9 DX,4u Telephone ( 81 ) 732-8 181 <br />