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DEPARTMENT OF PUBLIC HEALTH No. ..._ _. .._.._...
* __ J REGISTRY OF VITAL RECORDS AND STATISTICS
zlow, No. BURIAL (OR REMOVAL) PERMIT
9— OFFICIAL BURIAL (OR REMOVAL) PERMIT This coupon to be returned immediately,properly endorsed
(Issued under the provisions of Chapter 114. Section 45, General Laws, Ter. Ed., 6OAKD Of HEALTH — L01WW., MAbJ
as amended.) (Office issui permit)
[This permit can b .ned only by the a'ent of the Board of Health (or in towns /,00
where there is no of Health by th wn clerk) of the city or town in which CityOr Town of 7 Tr.L. Mass.
the death occurred ER the FILIN % acceptance o a satisfactory certificater _y
of death, p:nte typed in durgblio ek ink.] ,7
• IBC 7U 19 Name of deceased /. s.,14,rieAe- � .���°.�._-
' 0 .wn) (Date)
If a U. S. War Veteran,specif what war,organization,etc.
A sat' cry-cer ' cate death ha 'erg bee 1 , pe is ' er 've /j/-6
( , 1 Address)
for -emoval o L ��� "� , and the interment
(Tobe1lledoutincaseofremova ENDORSEMENT
a .10.‹h.../---- .,,may-' Cemetery in yram-' /Y ., of the
/(Q,L (To be filled in by cemetery or crematory o�iiaal)
body of .) ...... .. ell) C%�� who died ..C. `'f 1971.
ive full ned) (Month) (Day) (Year)
f / I hereby certify that the body accompanying this permit was
age /7`...? years, --� months, c l days. disposed of in accordance with its terms �` 2F.Zi
Ql ,,e
at
Cause of death ak-A-<-4--,,---'---- 7 .-
(Name at meteryca te or crematory) (City or town
If a U. S. War Veteran, specify what war, organization,etc. �/ 6 on .... C / s .A..
Residence at time of death ... if d / c � O/4, Certi ;�. t
Ayyyyy A
• 'G (• . of Superintendent,cemetery or crematory)
(Signature of Agent of Board of Health,or,in towns where there is no If there is no officer in charge, undertaker should sign and return this stub.
Board of Health,of Town Clerk)