HomeMy WebLinkAbout1940.01.Form I1VS-6-1.50y1-1U-38
COPA~9ONWEALTH OF PENNSYLVANfA
DEPA,R7['1VI~1Q1T OF HF1-'~I.TH
County, (~-.~-tr/.Cd'...
~~j BUREAU OF VITAL STATISTICS
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Borough, ....... __, BURIAL OR REMOVAL PERMIT l
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or Date of Death, _ ...... ~ .. !v _ _ _.. 19 .St4
City, .. .._... ...... ~~ '
Full Name, .....~;.~6~a-~~/ .... .:........ _ ......_.....................................................................Age,~/1~~~[s.,f .rJD..... Sex, .... (~................... Color,
._<~~,~~-Ct .........__.....
Disease CauSiccg De~tft, __.._ %~~ .. ~._.......h~>n t`rc'......~._._......_ _ ..........................................................._............................................................
..........__ _........._.-
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Place of Burial, ~ .... ,...... .~'.2.Gxz.~_..~.~`z.~...... .. ..G..........__ ............._._..._......,..._............................................._..:..............._.........._.............
...................._......
or 0
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Removal to, ........ _.... Vin, ___. ~ ... ...............
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Undertaker,/ 19Of.,.~. ~. ~~~~.z~ddress, ...(v ~.. G ................................ ~ .......~........../.~
A certificate of death having b file in my office in accordance with the Laws-of Pennsyh~ania, I hereby authorize the~yT~tt-.
of the body of said deceased person as stated above. ~ /M~%(~~~.~.c' [Burial or Removal?
-... _ ................. G?-rte......... __..................................................-
i~ /D [Registrar's Hamel
Dated _.. .......... _. ...... __ _ __ 19 -sl-O District No. ~~~._Ol' .~~~.......
Burial psi
Nhen the be
with a tram
s must be delivered by the undertaker to the sexton or other persons in charge of the burial ground or cemetery where burial takes place.
1s to be shipped to a distant point requiring the eervice of a co moron carrieq in addition to a removal permit the body must be accompanied
permit, containing the a8idavit of the undertaker, which must be attacLed to the box containing the body.
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