HomeMy WebLinkAbout1941.02.Form a~~s-s-IOoM-is•a9
COMMONWEALTH OF PENNSYLVANIA
DEPARTMEIoIT OF HEALTH
County, ........... tlr
pf~__~t?__~~/ _J ,., BUREAU OF VITAL STATI3TIC3
Torunslr.i '.. ~jtr7-`'~c //
or 11'0. 1...~:.._ :...........................................................
Borough, BURIAL OR REMOVAL PERMIT
............................................................
or Date o/ Death, ..... .,,,,(s.vS..~e~...........:~ ~_ .................. 19....~.~
City, ........................................................................
Full 11'ame, /Ltljri:L.1...... ... .... ~ ........_~i4 ~.r.{..... "!/',....1'}.1..~. ~.t..... _.... Age, _. _.._ ..__. _...._ .................. Sex, ... .. ............... Color, l...L.eLK_~~.......
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Disease C,arrsing Death, .... ...................................._-!..~.~.~........~:.....~!~...1..... ....... ........ ............................................
....
Place of Burial, ..... ................. ..... .. ........ ..................................... ............................................. .
or
Removal to, . .............~../..J..~...........................................~......s...,.~............................................................................. ['"ia, ....................
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Undertaker, ~...,...1.!..t,....~,nGr~..~:~~*~,~C~~Ls..l...~~!/Lc.! .................................... Address, .0~. ~?fYsrL..U-......... ........ .~...~.~...~.......................................
.........
A certificate of death having been filed in my office in accordance \cith the Laws of Pennsylvania, I hereby authorize the ..........................._.......
of the body of said deceased person as stated above. ~f _~ ~i ,~ [Burial or Remor~all
.............
~ [Registrar's name]
Dated ;_`~ .*.rtn-G.-.i..._...... ! ~'.~ .:. .. .........19.~~.I District No ~ ~."-:.~ ~
Burial permits must be delivered by the undertaker to the sexton or other persona in charge of the burial ground or cemetery where burial takes place.
\t'hen the body is to be shipped to a distant point requiring the service of a conunon carrirr. in addition to a removal permit the be~lc must be eccempanied
a~i[Ii a transit F<~rmit, containing the affida cit of the undertaker, which must he attached to the box containing the body.
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