Ross, John BOSTONIA •
>CONDIT 10,9 .
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ati#8 of Boston-Eq. admrnt of *Mil Sc *spats
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,0.L � legibly written in durable black ink,permission is hereby given to
1. YD Date of issue of p r it, �� 1 197 L
(Un taker) (Name) Address
for the removal from and the interment
�, /� �f(To be
filled out in c of re�moovvall)/HA ¢, Y
at LA/LQ., U.J�Jl�I1T JL/IIABLY iV l� -( l t `"i of the
+(hem•) 1 \1 ity or Tot)
body of Y``p,•�l/Ar�/_ ^ \ 1/V
(Give full name� of deceased) y�y
who died • 19 "UO ,age 4'Syears 6 months days
(month) (day) * (year)
:::::::::t:
CA ,/."�{
�
of death, /k
(Numbe (Street) My or To t t
Was Deceased a Veteran of any U.S.War
(Specify War)
CA / , ,t2___
Me-1005-REV.-9/72 DATAFOLD FORMS.INC. •