Katheryn WinslowH105.012- (Rev. 3180)
Commonwealth of Pennsylvania
Division of Vital Records
Full Name of Deceased
Cause of Death
Date of Birth
TA
Burial or Other Dis ositIL
of a Dead Human oy
Age Sex Date of Death
Veteran Status Race
(Yes or No) _ ..
te
Place of Death
f -
a Name of Common Carrier
Authorized Disposition (Check appropriate box)
Humanity Gifts Removal Shipment by Common Carrier
Burial Cremation � t—'�
L—.— County (If in Pa.)
Date of Disposition Name of Cemetery or Crematory
Disinterment
Idaix
ry
� > 1z Address
City, Borough, Township
Reinterment •,.,'�" T -a'^"
xtom'
z
een
red by
I certify tha I have met all the requirements of t e Vital Sttatistics Laws lawsrof thehstate. Peamissionlis herebysbfiled
given tothe Person ginlCharge
} t
and Regulat'd s. to transport and Ior make final disposal of the remains. .
Signature of Perso in Charge of Intetment _--1 '
i
Date Issued
Signature of Registrar
Address I certify that the deceased name above was buried or cremated
Mail To: in the cemetery or crematory named.
Division of Vital Records
P. O. Box 1528Date
Signature of Cemetery Official
New Castle, Pennsylvania 16103
Address
Rulate^^c
See Reverse Side for eg