Buddy, Elizabeth COMMONWEALTH OF PENNSYLVANIA
Hr . 12-2 rAscrs—izpo DEPARTMENT OF HEALTH
VITAL STATISTICS No. 3 8
PERMIT
FOR
BURIAL OR OTHER DISPOSITION OF A DEAD HUMAN BODY
FULL NAME OF DECEASED SEX RACE
Elizabeth Sampson Buddy Female Cauc.
DATE OF DEATH CAUSE OF DEATH - AGE
1-14-73 Hepatic Failure 74 Yrs.
PLACE OF DEATH CITY, BOROUGH,TOWNSHIP COUNTY
3ryn Mawr Hospital Lower Merion Montgomery
AUTHORIZED DISPOSITION(CHECK APPROPRIATE BOX)
B BURIAL REMOVAL CREMATION SHIPMENT BY DISINTERMENT REINTERMENT
COMMON CARRIER
NAME OF CEMETERY OR CREMATORY LOCATION(TOWN,TOWNSHIP,COUNTY)(STATE) NAME OF CARRIER(IF SHIPPED)
Pine View Cemetery Glens Fit1ls,Warren Co. N.Y.
I CERTIFY THAT I WILL COMPLY WITH THE REGULATIONS OF THE DEPARTMENT OF HEALTH RELATING TO THE TYPE OF DISPOSITION STATED HERE.
1 ir,C, �� �. � r 104 Cricket Ave. Ardmore, Pa.
SIGNATURE OF FU Pr
-(RECTOR ADDRESS
I CERTIFY THAT I HAVE ASCERT• D THAT THE REGULATIONS OF THE DEPARTMENT OF HEALTH WILL BE COMPLIED WITH AND HEREBY AUTHORIZE
THIS Bur is
• BURIAL,REMOVAL,CREMATION,ETC.
1-15-73 f
DATE ISSUED • —�—E� RE IS A S SIGNATNATU
MAILING ADDRESS z Pd:C."
FOR BURIAL, REMOVAL, OR CREMATION THE FUNERAL DIRECTOR SHALL DELIVER TWO COPIES OF THIS PERMIT TO THE CEMETERY OFFICIAL.THE CEMETERY OFFICIAL MUST
RETURN ONE COPY TO THE LOCAL REGISTRAR OF THE DISTRICT IN WHICH THE CEMETERY IS LOCATED.
SEE REVERSE SIDE FOR REGULATIONS