HomeMy WebLinkAbout1933.01.Form V. 6. 0-100;11
COMMONWEALTH OF PENNSYLVANIA
D PART1i~IENT OF HEALTH
County, ---•--- ------ --- -- - -
BUREAU OF VITAL STATISTICS
Township, - .--- ----._... ----.....~
or BURIAL OR REMOVAL PERMIT No. ~ . ~•-..-. - •.
Borough, ~ - - . .-....-..
or Date of Death,........ ,~~.-19>3
City- ------------ ---- ---- ---...-- ----------
Full Name, --- -. .... ...:~.'.~~L/-L/L/.l..Fi~Age,. ... ~ Sex,... .. Color . ............ _
Disease Causing De ~ --- -•• -- ...... ....... .... .... ... ..... ............ --_-- --•-------•---•--••------ -.................-- -.....-------•--°
Place of Burial, --•• --------• - •• -- - ...----. " ... .... -.. .......................................
or
Removal to . .. . . .....................•-------. .... -. - - ..._---• -•--......-......--------...................--• V~ -----......---••-- -.. ..-----..-...... .........---•---......------
••------...----
Undertaker . ........... . -- ---• ----- --- - - ..t:L..~t~------------ Address, ............ --. ~~:
A certificate of death having been filed in my office in accordance with the Laws o Pe nsyly ia, I h reby authorize the-..
of the body of said deceased person as stated above. ~ ~ ~ ~ ~ ~ ,~ , [~ial or A a "
` / t _ - - ~ [l~gibtrai's name] % - _ ~ -
- - •--•• .. ............ ....--........... ----19..,,1..... .......-..ll ..-...... ~ --...----....
i permits moat be delivered by the undertaker to the aezton or other pe son in c rge of the burial ground or cemetery where burial takes place.
e body ie to be shipped to a distant point, requiring the service of a co mon cam in addition to a removal permit the body moat be accom-
with a transit permit containing the affidavit of the undertaker, w must be attached to the boz containing the body.
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