Waters, Stephen Form V. S. 6-100M 4...-yr-‘-26.01 JP/ /foie" ••)•.; /:;:;:'"r"I"l'"':") . ' •
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
county, :(70;2„.4' 3. ... . ) p.:wcti,,j
, OF VITAL STATISTICS
•Ik -19
Township,
Or BURIAL OR REMOVAL PERMIT
Borough,
Pt:lb'
City,
Full Name,Rkr---- --are,.-7/9 Sex, Color,
! .•••
Disease Causing Death, ..
.•
Place of Burial,
Or -
Removal to, . Via,
Undertaker, Arri Address,
A certificate of death having been filed in my office in accordance with the w Pennsylvania,I hereby authorize the
of the body of said deceased person as stated above. [Burial or Removal]
"..-
[Registrar's natne] —2
Dated 19 -District No.
Burial permits must be 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 shipped to a distant point, requiring the service of a common carrier, in addition to a removal permit the body must be accom-
panied with a transit permit containing the affidavit of the undertaker, which must be attached to the box containing the body.
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