Moody, William R-309 OIllt Mitinnuntwealth of ,',:assarbuortto R-309
JOHN F. X. DAVOREN No. 0
* - SECRETARY OF THE COMMONWEALTH .303
BURIAL (OR REMOVAL) PERMIT
OFFICIAL BURIAL (OR REMOVAL) PERMIT This coupon to be returned immediately,properly endorsed
Board of Health
Division of (Issued under the provisions of Chapter 114, Section 45, General Laws, Ter. Ed., to
Vital Statistics as amended.)
(Office issuing permit) —,
[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 cle of the city or town in which IXIIERLY MASS
the death occurred AFTER the FILING and acc tale o(' a satisfactory certificate City or Town of . ID i c Mass.
of death, printed or typed in durable black ink] z.
aEVERLY,..MAS§x 'el. ( 4- 19 -,,
, -1 .:) Name of deceasedUcj..47-t/.114, ' ' 7 ,i4, 1-17
L,ity or town) (Date)
.t ' isfactov certifica -)if deat havingVed, ' h eby given
IAA I alY If a U. S. War Veteran,specify what war,organization,etc.
permission
( ae) ddress)
Ci
(
for removal om , a d the inter nt
T
u,...irx.A.A.)(To be tilled out in case of remova f
riO „n - Pi
Cemetery in . Q,Ai.l5 \WW.)..., of A. ENDORSEMENT
body of ... s?....- -aii,p,A.ak.0:-. .(,,, ' .ei-..),..1.01..- who died .) 0 tef .--.1 (To be filled in by cemetery or crematory ofhicial)
(Give full name of ceased) (Month) (Day) (Year)
I hereby certify that the body accompanying this permit was
age ::V.:. ears, months, J. ° days. disposed of-i-11-47 accordance with its terms ,
)
c --
Cause of deat '.9..7\1A(..2 ' , -109..A.... aQco tc-L,4----*
at ,../
---) (Name of cemetery or crematory) (City or town)
, -
If a U. S. War Veteran,specify a war, organiz017,etc. - on .,... / / /
-4 1
Residence at time of death .. .a?.),.111n...... ... -• aV ...A /- ,. K
i?\tert., Certified by, i -
(04)ah • '—'-'711 CX.-4 ., - (Si ture of Superintendent,cemetery or crematory)
( ture f Agent of Board of Health, in towns where there is no Tf thewe is no officer in charsee. undertaker should sign and return this stub.