Flint, Lester HD01232F Rev.11/11
COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS
DISPOSITION / TRANSIT PERMIT 1442745
(See reverse side for completion instructions) No.
Section A—Local Registrar or Fti rat Director
Transcribe information as listed on Certificate of Deathper res ondi item numbers in parentheses,
Full Name of Decedent(1•) Sex(2.) Date of Death(4.) Date of Birth(6.)
2 9s7e3 Jo Ft i �'� �—1 Z—lr /eviz 4 --1
Cou,Ipty of Death(15d.) Citr,Boro,Twp.of Death(15c.) Fac'ity Name(15b.)
1— a efeeiilidaiti4`.4 )1✓-H ere_ Sri� c p�`/)1
Was Decedent ever in the U.S.Armed Forces?(9.) Ce's ❑ No ❑ Unknown
Cause of Death(26.)
Authorized Method of Disposition(Check all that apply)(16a.) Date of Disposition(16b.)
❑Cremation(Authorization No.,if applicable) or verbal OK per: p
NAME/DATE �'/ J t
L vial ❑ Donation ❑ Other(Specify)
❑ Removal from Pennsylvania(Specify method of removal,if applicable
Place of Dispositi n(Name of cemetery,crematory,or other place as listed in Item 16c.)
Location(City/town,state,zip code as listed in Item 16d.) County(if in Pennsylvania)
SIGNATURES BELbW CERTIF(THAT APPROPRIATE INDIVIDUAL HAS MET ALL REQUIREMENTS OF THE VITAL STATISTICS LAW 35 P.S.,§450.504,
28 PA CODE,CHAPTER 1,AND ANY OTHER COMMONWEALTH LAWS REGARDING DISPOSITION OF DEAD BODIES.
Section B—Local Registrar
Sign nd district number of Local Registrar issuing permit: Was this permit released as a blank pre-signed permit prior to filing the
death certificate?
► 7irf.
1 31 51 31 21 71 1.1 Yes ❑ No r�
Complete A : Division of Vital Rec ds,Scranton Office If yes,date released to funeral director: I/—
100 Lackawanna Avenue,Room 112
Scranton,PA 18503-1928 If no,date permit issued by local registrar:
Section C—Funeral Service Licensee- Section D—Cemetery or Crematory Official
(or person in charge of Interment}
I certify that disposition has been completed by method(s)authorized by
Funeral Director License# CJ1/Y3 0 U this permit in the location as indicated.
Signature of Funeral Service Licensee(or person in charge of Interment): Signature of Cemetery or Crematory Official(or representative of facilit
receiving donated remains): /
. Date of ei/z/osition ! /
Date ► Dis► Gr�,� a e ` 1�" �' P
Complete Address _ kr)/l no#`B/.1' mplete Address
141p6,3c,3 dpiei . 141
INSTRUCTIONS FOR DISTRIBUTION it
This permit is valid for 30 days only from date entered in Section C of this permit.
Copies 1,2&3: Issuing local registrar provides Copies 1,2,&3 to funeral service licensee(or person in charge of Interment)who must
provide these three copies to cemetery/crematory official or representative of facility receiving donated remains. If there is no cemetery
official,contact the Division of Vital Records at(800)842-5040, select option 6,option 2 and then option 4. Upon completion of
disposition, cemetery/crematory official or representative of other facility distributes copies as follows:
(1) Cemetery,crematory,or facility receiving donated remains retains for their files.
(2) Submit within 10 days to the local registrar in the district where cemetery,crematory, or other facility is located. Contact
the Division of Vital Records at(800)842-5040,select option 6,option 2, and then option 4,for the name and address of
appropriate local registrar in district where disposition occurred. If place of disposition is not located in Pennsylvania,
copy 2 should not be returned to the local registrar and should be filed in accordance with the respective state's policies.
(3) Submit at the end of each month to: Division of Vital Records,PO Box 1528, New Castle, PA 16103.
Copy 4: Issuing local registrar retains for his/her files.
COPY 1