HomeMy WebLinkAbout1942.02.Form HVS~-150M-1-41
COMMONWEALTH OF PENNSYLVANIA
~ DEPARTMENT OF HEALTH
BUREAU OF VITAL STATISTICS
or BURIAL OR REMOVAL PERMIT / /~ ?, '
Borough ..............................._.............. 4 /fi R/ ~`~7
or Utttr of Drallr, _.._......... _. _._~ :........... ......... .. ........'°.......19.
City . ............... ,~.............. ...... .
i _ ,~
Full Nan:e,/~?!~L~~~. . ..r .. .,J.~~.. . ...-~ ... .............................Age,... ~t/'........-.............Sex, .............~.-...............Color,......~~~.<........
Disease Causing Deal/t,... /. i" i....•....••......... ,/~. .
Place of Burial, v,..... ~Q......~"..C..!/!~-.~.........~:r:".~is` .... ... ...r ......................................................................................................................
.....
Bemoral to. ......................:..~......... /.. ~... .... :a,...............••~f......... ................. J
or ~ ... ... ~~..
~Z.~ 1. ... ddress,..
Urule~lahrtificate of death Navin r en led in my office in accort ce with the Lai .~...... ~. ~~ .~...~.~~ .~.•~ ...."•.. ~.
ce ,~ cs of , vlvania. I hereby autho ~ e the... _.`
~_~~~ I~ 'ial ortZemeral].....
of the body of said deceased person as staled above.
,.
~ .............................................._... .. ..... K'~~... ................
/l ~ (Registrar's namtJ
Dated.........,. ~ ~7 .~~........__ _ . l~+''Fdj Ihtfrrrl :\'o.....
J
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Burial permits lust b~~ delivered by the undertaker to the sexton or other persons in charge of the burial ground or cemetery where burial takes place. When
the body is to be sJ~;rped t~~ a distant point requiring the service o[ a common carrier, in addition to a removal permit the body must be accompanied with a transit
oerm(t, containing the affidavit of the undertaker, which must be attached to the box containing the body.