Buckbee Jr., Neil Form V. S. 6-100M
COMMONWEALTH OF PENNSYLVANIA
ilzt DEPARTMENT OF HEALTH
CountikVf6_ -
BUREAU OF VITAL STATISTICS . ✓��/
J.
Township, N
or BURIAL OR REMOVAL PERMIT '
Borough, !
or Date of Deatit, .X._..... ...-19-...e..ee
City, if4 ✓ ex,,- ..
Full Name, _ � � Q 0 /�,
u`�-' .. i _._.._Age, ._.... Color.
Disease Causing De h, Lz .�.iL�.... .»...._ -...� ..�rt- 1
Place of Burial, ..e!. . _ .. .1 C[ �J
or
Removal to, » » _.....t Vie, • .
t)
Undertaker, �L4� ».. Address,.. :.cY. 1‘726..
A certificate of death having been filed i office in accordance with the Laws of Pennsylvania,I hereby authorize the
of the body of said deceased person as stated above. —, [Burial or Removal]
._..,, =-c. 22/4 4Kl i
/ [Registrar's name]
c.Dated. �'. 4 `sr' l 6 19..._....... District No
Burial permits must be delivered by the undertaker to the sexton or other pe rsons 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-
pamed with a transit permit containing the affidavit of the undertaker, which must be attached to the box containing the body.
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