HomeMy WebLinkAbout1942.03.COMMONWEALTH OF PENNSYLVANIA
~ DEPARTMENT OF HEALTH
Co a rcly,(1 ~,!.li. ~~K`'ir-;. «-.:: X ..'...
' BUREAU OF VITAL STATISTICS
~/
TomnshiT l!. '. ~...........,t~~iryr.`. iVo ................._:..........
BURIAL OR REMOVAL PERMIT
or ->
13mouylc,.... .......................................... °~ - ~~
or Date of Deafh. ................. ~~G`...:.. ~.......3J~....... r.~............19.~.~`,~ it
Cit ,~ -
y,...........1 ............. ................. /~~ ~ /
Ftdl R'ame,~ . ..~. ...........[~•~ ~F~%i ...........................Aye,...(1~~~'.............Sex ,/.f~.~4«4..........Color,.~~~. .c~..._....
Disease Causing Dea~.. .Cf„L. • ............. .....-.... ~.............................................................................................................................................
.........
Place of Barial,....~- ...................:....~:.e`...........r.....v.;:l~'r.~........................................................................................................................
...................
or
_ ~1i ~ _
A certificate of death hating Geenlfiled in my office in
of the body of said deceased person as stated above.
~•
ta ..................
with the T,a«-s
~~s'<
H ',.
Daterl...~f..-~! f°~.f........~.....:' ..:....................19.F~r~'
Aurial permits must be delivered by the undertaker to the sexton or other persons
the body is to be shipped to a diatant point requiring the service of a common carrier, in
permit, containing the affidavit of the undertaker, which moat be attached to the boa <
...............................................
Thereby authorize the.,.~.~~~~~'l.._.
% .[burial ec.3temnvall
/l
l Registrar ........... d{' ... ~'~ ..................................
's name] n'
of the burial ground or cemetery where burial takes place. When
to a removal permit the body must be accompanied with a transit
the body.
I
' t^
~~ ~
3`
p 1 V
e
K
Q
Y