HomeMy WebLinkAbout1946.01.ii~'5-20012-1SO~I-3-da -10
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
County,
-' oyy~~~~'~ BUREAU OF VITAL STATISTICS y
Township, !l ~....~~~r No. _ . _ ....~~/
~ _ _ .. _ ..._C...r ............................
or BURIAL OR REMOVAL PERMIT ~°
Borough, ._ _ ............................................... _.... .
or Date of Death, __.. _......_....G....._.~~.lr~....!t.__.......19.~~`i
City, . _ .............. ....... ........
Full Name, G_ /~~~_ ... _......... Agee . Sex, .. ~~«?._...._. Color,~~`~ ........
Disease u ting Degt~ l' .. ~..... _.. _ __...... _........ .... _._. _._ _ _ ....... .........................................
Place o Burial, a,C%d ,_ ..... ... ..~. ....~ .. ...... ......... _..
or
Removal to, _. Via, .__ .
Undertaker, _ _ . _ L ......--.... .~~-_ ....__.... .....Address,
A c at~e~~of~_~ath' having been filed in my office in accordant ,
the ~;.%~~,ry .. _ of the body of said deceased person as state
~1 L ...~.
Dated
19yb
'~~~Gra~..... .......................................................
ws of Pennsylvania, I he , y authorize
~ ,~ '
[Ref,+istrar's name]
District No. ..~1'..d_~...'...~/._...........
Burial permi4s must be delivered by the undertaker to the sexton or other persons in charge of the burial ground or cemetery where burial takes place.
\4'hen the 6,•dy is to be shipped to a distant point requiring the service of a cnuunun carrier, in addition to a removal permit the body must be accompanied
with a transit permit, containing the affidavit of the undertaker, which must be attached to the Los containing the body.
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