Ricketts, Edward `- va Y S.jJns�as+sa__-c - - ----- -. ,
EDWARD J. CRONIN
Ik. SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
� No.
is"
OFFICIAL BURIAL (OR REMOVAL) PERMIT
--, - - (Issued under the provisions of Chapter 114,General Laws,as amended by Chapter 176,Acts of 19z2,
Chapter 243,Acts of 1926,and Chapter 48,Acts of 1927.)
[This permit can be signed only by the agent of the Board of Health(or in towns where there is no
Board of Health by the town clerk)of the city or town in which the death occurred AFTER the
FILING,a,i1,441ccePtance of a satisfactory certificate o ,.eath,legibly written in durable black ink.]
44," 1`11 - O'er' .194..
(City or to ) (Date) r
certificate of death having been filed,permission is hereby given to ,.
-iy-4 , :„*...,—cri,..ig.,
A satisfactory
(Name) (Address) . .
for the removal from , and the interment
(To be filled out in case of removal)
at Cemetery ui/. .1 fF.l.. 1..4 jL s f thi
who died.... a'd 194 1
body of.... ft-•. ..
(Give full name of .deceased) (Month) (Day)t (Year
age 7e5 years, months, days.
Cause of death
If a U. S.War Veteran,specify what war,organization, etc.
/ _
Residence at time of death ' ,`r• Ple•• -
(Signature of Agent of Board of Health,or,in towns ere there is no
Board of Health,of Town Clerk)