HomeMy WebLinkAbout1941.01.~ Form HtiS~6-150Ji-12->9
COMMONWEALTH OF PENNSYLVANIA
~~_ / DEPA~tTMEIiiT 4F ~--IEALTi-I
County, .-.~2~1!?~,c:,~-~ ~~'
Towrtship, ......................................................... BUREAU OF VITAL STATISTICS ~
Borough, N..;~%2ill~ ..^ ............... BURIAL OR REMOVAL I'ER641T ~ - ~~-
or Dute of Death, ~''~ /._1` ~•
City _ ......__. I9_ ~L
// _
~ 1
Full Narne, ,,r'..f' .......~.~......~ - ....................._ A,~e, .-_.....X~.' J~............ Sex, ........... Color, ~L:c~..................
Disease Causing De~ __ ......_ ..........................................
Place of Burial, ..!/... .. `:......,~......1.../...:......,~~.T..L~i~E/ ..............................................................................................................................
............................................................................................................
or
Removal tt1L.... ~.~ ~ . _. _ __. Via . ..... ............... .............. ................................. .................................................................
!~ ~ .....
................
Undertake ..., ._~7d~/~YL.......:: Ir.....~_ +'iP...~......•.... Address, ...S.r......._v..~fY(/Cra- .................. _ ......................
A certific `~ of death j~avi~g been Sled in my office in accordaaee ~sith the Laws of Pennsylvania, hereby~uthorize the%..~C
of the body said deceased 'person as stated above. _~ `~.-G'~ . [Borial~3
/~,~, ~^ [ ee atrar's name]
Dated ......./~ ~'~- •.........1...~....'..' ......................19..~~ District No. ~l O ~ d /
Burial per~ite moat be delivered by the undertaker to the sexton or other pereo[16,{n charge of the burial ground or cemetery where burial takes place.
When the bpdy is to be shipped to a distant point requiring the service of a com carrier, in addition to a remove! permit the body must be accomnani:•d
with a trn~si6 permit, containing the atRdavit of the undertaker, which must be. attached to tLe box containing the body.
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