Clark, Andrea tt\4`O� Boston Public Health Commission
((��' ((}} f .. BURIAL PERMITS DEPT. � 3 1 D
Rbo` RpSJ nCY Q m m�n ��+a p a Jt li � i �I� # R-309-10 1010 Massachusetts Avenue
Q a a No....$ k .'
6o5kO v,PPps 0,C"s�'''ti5 No. ,)t i 4, ,,C Boston,MA 02118 >Ir}'; 'ko•t.rt..•
1 ', S F ICIAL DISPOSITION, REMOVAL OR TRANSPORTATION PERMIT DISPOSITION, REMOVAL AND
(Issued under the provisions of Chapter 114,Section 45,General Laws„Ter.Ed.,as amended) TRANSPORTATION PERMIT `,-,
This permit tan be signed only by the a t of the Board of Health(or In towns where there la no B rtl of Heehh by the town clerk)sl Me city or
town In whkh the death occurred A. the FILING acceptance of a sa5arectory cenmaete oI ' •printed or typed M anent black Mk. ^ �3
� '� This section to be returned Im ately to the I ulng Clty/rown,properly endorsed
ty /
City/Town/Town .___ D e • _1...�.,..20 L r•'.--_.� totc. wff GSA
A satisfacto�LA...,„.
y$�eath certif;i}),,ate having been filed for irk
y�\� +ri((�' (Office issuing permit)
`A...-.1,,4 tf:•."'1..Q_._-Z.',,,` , f ,�.,,,„L, �^Q tom, 1,,,\,,^, •�
rrii" "ti. ,,
City/Town of yyy'''''' Mas
Full a of dace ant .-� � 4�
C.
who died on �,� r 13 1 '' /_ S War Veteran j Name of Decedent
LLL/// date of � ' ��
jA If a U.S.War Veteran,specify what war,or nization,e
bornylt ....?p,4,,,,,1,-- 1 `Ftw esided at „{
/ ('";,- dale bitth) J'•SY A`�-• '"" 7 N.
ut- /1,--14-NP--t..� & (-- ENDORSEMENT
�J p
and who died of ..6 ''•'--" � � (To be Wiled in by cemetery or crematory official) 1
give i edtate cause
Permission is hereby given for(check all appropriate xes): 01..,O C y--c-t.,_..-1.. -t __ I hereby certify that the body accompanying this permit was
[ ]Removal from: disposed of in accordance with its terms//•
r, _�'' name and add of o' 1'�dyisp(o}siHon '7(��,,.�,,(, at I / _._ tel)
R ,\c{I( f�!� i�`./` t io�Jy� _!L " M/cr u V IT/T�(City/Town)at: (Name of cemetery or crematory) (City/Town) r,
name and address of cemetery or crematory 0\,
[ 1 Transportation to:
on 7i`UNEs (6) ( 20(1, h•.
name and address of immediate destination of remains f .,ir I 2 v}I,
Final Disposition
t
Fermis ' is hereby given to• r-t_. /� ""b._.�" p
Certified by �
,L> -e' c'bty `' (A-4—''1_t' .,,,L,y (Signature of S erintendent,cemetery or crematory)
"
addres`. facility
J If there is no officer in charge,funeral director must sign and return this stu
Signature of Board of HAent,or,in towns where there is no Board of Health,of Town Clerk)