Moss, Bertha Form D
STATE OF MAINE BURIAL PERMIT
Z/ 6 LISP Me.,S(.4 NE" 2_ 1937
,Permission is hereby given/1/4 4'3 liy Wiht.d..4" C .
to remove and bury the remains .4 of 1-14/4 AlA ti Alck5 S
in p,4/E /poCemetery, Town of6a/V-frxii15), 41/
Date of Deatija 11/E -2-3 19V, Age...6 years r months 2, Z.days
Place of Death Gli..c7 E4e..67./etClir4;e1 60-r/37,14
Cause of Death CE4'e,e574'4i n -Ald R 4,4
giPAY17.74-4/sio*- liRremo-
Medical Attendant. lie4/EL N/1/ /Y fit
No s‘tle City- 7 MUM eterk
(Over)
Si. Registrar
•
Li t �jL t e G/ - 6- / 9 S
// Y�
L..�`
-"c7 .444
Signature of per n having charge of cemetery
This Permit must be returned to the Clerk of the town or
city in which the burial takes place, within SIX DAYS after
burial.
Any person acting as Undertaker without a Burial Permit
will be subject to a fine not exceeding one hundred dollars,—
Chap. 1, Public Laws of 1933.