Jodan, Laurence i GUMMUNWEALTN OF PENNSYLVANIA
, DEPARTMENT OF HEALTH ! /
Hlos.olz-zooM sers-Rev.retza VITAL STATISTICS No. "� �'
-
PERMIT
-_ FOR
BURIAL OR OTHER DISPOSITION OF A DEAD HUMAN BODY
FULL NAME OF DECEASED € SEX', RACE
r r - :_ i
DATE OF vEATH) CAUSE OF DEATH 1 AGE
/_
" -, �
r
C .r_—c—-?:=4-----A--C" t Lde. -'e—1"/
PLACEpF DEATH CITY,BOROUGH,TOWNSHIP _ . COUNTY '.
AUTHORIZED DISPOSITION(CHECK APPROPRIATE BFIX) A,1.�� a -
i
BURIAL REMOVAL CREMATION SHIPMENT BY DISINTERMENT REINTERMENT
COMMON CARRIER
NAME OF CEMETERY OR EREMATORY l _ , .. LOCATIOV(TOyIN,TOWNSHIP,COUNTY)(STATES)-. ,� NAME OF CARRIER(IF SHIPPED)
(y/// y ,f , C.i
I CERTIFY THAT I WILL COMPLY WITH THE REGULATIONS OF THE DEPARTMENT OF HEALTH RELATING TO THE TYPE OF DISPOSITION STATED HERE.
J
SIGNATURE OF FUNERAL DIRECTOR ADDRESS
I CERTIFY THATYHAVE ASCERTAINED THAT TIME REGULATIONS OF THE DEPARTMENT OF HEALTH WILL BE COMPLIED WITH AND HEREBY AUTHORIZE
THIS ,fir��.- /
BtM'Ai C,-1ErnIOVAL,CREMATION,ETC.
l7 DATE ISSUF,D REGISTRAR'S SIGNATURE,-
f5 / _ ' • i
c-- 7 I „6 '1:, -'L-..; \.- Z g_ .,'' L
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