Clark, William R-309 Mg KYouttnnituitttltli of itlassFC.rlmortio
EDWARD J. CRONIN
SECRETARY OF THE COMMONWEALITaH
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"•'J_= OFFICIAL BURIAL (OR REMOVAL) PERMIT
Division of (Issued under the provisions of Chapter 114, General Laws, as amended by Chapter 176,
Vital statistics Acts of 1922, Chapter 243, Acts of 1926, and Chapter 48,Acts of 1927.)
This permit can 'gned only by the agent of the Board of Health (or in towns where
there is no Board f ealth by the town clerk) of the citr town in which the death
occurred AFTER t e ILING and acceptance of a satisfactor certificate of death, ibly
written in durable c ink.
•.Q-C....• Y1...19-3
(City or town) (Date)
A Octory certificateI death havingJd, pe
r fission is her 1, iivep.
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• 1/44.-1- . . �(A dress)
(Na
CSAfor the - oval froy.' To
_- , the be filled t in case of)removal)
at Cemetery in.. ... _ ..... -.5)••, of t
•
} ' , Q Q. who died Li- )-`� 1 0
body of �1`�...(Give full name bf deceased)
age — year uS.-months, days. .
I
Cause of death .. lt�... ••0. . LA.-.. .Q li lat:tits
r
If a U. S. War Veteran, specify w war, organization, etc.
Residence at time of death
(Signature of Agent of Board of Health,or,in towns where there is no
Board of Health,of Town Clerk)
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