Gordon, Francis COMMONWEALTH OFPENNSYLVANIA
DEPARTMENT OF HEALTH
H105.012-200M SE ,._. " --
VITAL STATISTICS No.
PERMIT
FOR
BURIAL OR OTHER DISPOSITION OF A DEAD HUMAN BODY
FULL NAME OF DECEASED 17SEX RACE
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DATE OF L(EATH�y --- -.. -.. --.CAUSE OF DEATH AGE
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PLACE,OF DEATH CITY, BOROUGH,TOWNSHIP - • COUNTY
L..AUTHORIZED DISPOSITION(CHECK APPROPRIATE BOX)
1 SHIPMENT BY
BURIAL REMOVAL CREMATION COMMON CARRIER DISINTERMENT REINTERMENT
NAME OF CEMETERY OR CREMATORY „r'I LOCATIO (TOWN,TOWNSHIP,COUNTY)(STATE) NAME OF CARRIER(IF SHIPPED)
I CERTIFY THAT I WILL COMPLY WITH THE REGULATIONS OF THE DEPARTMENT OF HEALTH' ELATING TO THE TYPE OF DISPOS)TION STATED HERE.
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' SIGNATURE OF FUNERAL DIRECTOR ADDRESS
I CERTIFY THAT I HAVE ASCERTAINED TI-IAT THE REGULATIONS OF THE DEPARTMENT OF HEALTH WILL BE COMPLIED WITH AND HEREBY AUTHORIZE
THIS �� � �
/,, BURi,�'C;'RJIOVAL,CREMATION,ETC.
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/ DATE ISSUED REGISTRAR'S SIGNATURE
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4 ! MAILING ADDRESS
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 •