Hudson, Kirk \.vmwwI`I VY GAL I VI .Jr rG191\J I L V A191A
DEPARTMENT OF HEALTH �/
H105.012-250M sets-72/70 VITAL STATISTICS
No.
.751
PERMIT 7 S sGG)
FOR •
BURIAL OR OTHER DISPOSITION OF A DEAD HUMAN BODY
FULL NAME OF DECEASED 4�`� '�L SEX -_.„
.1..„ RACE 2:44'7
DATE OF DEATH CAUSE OF DEATH AGE
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PLACE OF DEAT ITY, BOROUGH,TO SHIP COUNTY
Y
AUTHORIZEDlA
�/ DISPOSITION(CHECK APPROPRIATE )
/� BURIAL x REMOVAL CREMATION SHIPMENT BY DISINTERMENT REINTERMENT
Y ' ` I L/I COMMON CARRIER
z,,F CEMETERY OR CREMATerf— LOCATION(TOWN,TOWNSHIP,COUNTY)(STATE)
q,,,, NAME OF CARRIER(IF SHIPP D)
47,,,,e„,,,_,
•
I CERTIFY THAT I WILL COMPLY WITH THE REGULATIONS OF THE DEP TMENT OF HEALTH RELATIN TO THE TYPE OF D .SITIO /.TATED HERE.
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SIGNATURE OF FUNERAL DIRECTOR ADDRESS - -- -
I CERTIFY THAT I HAV ERTAINED TH T THE R �TIO�NSS OF THE ARTMENT OF HEALTH WILL BE COMPLIED WITH AND HEREBY AUTHORIZE
THIS I /I-�/�"7�
• BURIAL,REMOV CpiAMeFf6 Wiarilty-Oe
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DATE ISSUED wSwo eeE BulZC�ing
Pittebureh
300 Liberty
Avenue
t� FittsburgiuLINt4eDRES55222
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