Potter, James BOtZ13:A
r�CONDITAADy
•
1.I630. ��'
Qtitg of 3oo#on-fl4tuttmnd of gill & Wooiiialo
BOSTON CITY HOSPITAL
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(Issued under the provisions of chapter 114, General Laws)
All the preliminary requirements of law having been complied with, including the filing of a
satisfactory certificate of death, legibly written in durable black ink, permission9 is hereby given to
c ; ;2 '
ate of issue of permit, t _pr� /, o2 197€-4 . n Z
(Undertaker) (Name) Ad ss
the removal fromlez
and t e interment
a d/y,/ ) To a filled outt.iinn+case of remo/v�aLyt vhe
,77/ _ _ !v/ ,, ,,,,„
em.) �` ity or Town)
body o . 442/1.111 .
`(Give full nameT
of deceased)
who died if.1, // 19 ,age/l years 7 months 7 days
(mon (da ) (y /
Cause of death, ���
Residence at time of death, re) j �j
(Number) (Sire ) (City r )
Was Deceased a Veteran of any U.S.War
(Specify War)
Nis-1 Goti-R /72 '9/DATAFOLO FORMS,INC. •