HomeMy WebLinkAbout1941.03.c F~~uu 11\"5-6-160M-14-89
COMMONVYEALTH OF PENNSYLVANIA
corral}-, (~~,,,,,n,~r.~tn.~,~.,,. ~ I3 E P A R T M E N T OF H E A L T H
(~ Js BUREAU OF VITAL STATISTICS
or BURIAL OR REMOVAL PERMIT'
Borough, . ........................................................... ~/
or Date of Death / Q ....................... 19[~.~
City. ...__ ............._...............................................
~~~
Full Name, e..,f'{.~..ri..~..•E..S......,S.C.r..C2...~_.Z ..........................................................Age, ..~U....~~........... Sex, ~.LR.,d.F%......._........... Color,
. ...`..........
Disease Causing Death, et.Grl.. ..... .. ... f,...lLq .. ~,Q.'L`...~..4w.ww~.~'7,~M1...../11~.t.~.'..~ ..............................
Place o/ Burial, ............ .. leL...... . .
I .................................................................................................................................................................
or
Removal to, ...._ ............................................................_....__._....................._... _......._..._.........._............. _.Pia, .. ...__._ _.............................
................................................................................................._.................................
,... ~
Undertaker, ~ ~..1........ rt.~i.._i,._. ........................__.....Address, ........ ... ~~..j...........................................................
A certificate of death Laving been filed in my office in accordance with the Laws of Pennsy ania, I hereby authorize the~.wt/3,L,a.::^...
of the body of said deceased person as stated above. /, [Rurial or Removal]
/ ' [Registrar's name]
Dnted~ 1~:~.._ ......_. :......................................._.........19..4:... District No.~._!._`.. '.......~.
Burial permits moat be delivered by the undertaker to the Seaton or other perFOnE in charge of the barial ground or cemetery where burial takes place,
tA'l~~n the body is to be shipped to a distant point requiring the service of a connnor rar,~irr. in addition to a removal permit the body moat be a.ecomparird
v:lth a tr;~nsit. p~•rmit, containing the affidavit of the und~•rtaker. which must i~•- :: ,,,, i.~~i 'r. thr hox containing ttae body.
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