HomeMy WebLinkAbout1943.01.COMMONWEALTH OF PENNSYLVANIA
county, DEPA~2TNIEP~IT ®P HEI~LTH
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yJ/~ BUREAU OF VITAL STATISTICS
Toumslzi p,..: s":.~:~'j.~~ No .....................~.. /...7 ;...................
or BURIAL OR REMOVAL PERMIT
Borougiz ............................................... '' ~t
or Date of Death.. .........................~:~.....~°~.!,r............19.'T`v1
City,........ ............................................ '' /~
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FuU Name.s....'.:....; . ....,. ~w..~'~~/.r"lJ ..................-.................................Ape,.........,l.K~..... ~~ Ses, ......~f.~c.,..........Color,....d..!. ....L......
Dzsease Causing Deat)~ ... ......~..r .......................................~. ~......
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Place of Burial,......... - ..//. ~ ~ ............................................ ~ .... ~~.... ~~?~-~!/~--z-~
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Removal lo, ..............................,......,,.......................:'......~/...........................::`..... via.........
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Underfaker, `~'..rU...:.,~ ~~ ,`' •~~....F~ ~z.~r.E:~ll~f':. ~.........;..tfdd~~tr..... .. f~..~ . .. t~r..~.-pct
... ............ .. . u..... .....,... .. ..... ..........
A certificate of death having been filed in my office in accordance with the Laws of Pennsylvania, I hereby authorize the .:, l~-~C ...~
of the body of said deceased person as stated above. - [Burint otl3e:eevei}~
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Burial parmi!s ~.nust be delivered by the undertaker to the aezton or other persons in charge of the burial ground or cemetery where burial takes place. When
the body is to be sh!pped to a distant point requiring the service of a common carrier, in addition to a removal permit the body moat be accompanied with a transit
permit. containing the affidavit of the undeztaker, which moat be attached to the boz containing the body.
Form IIVS~i-160M-2-42
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