Van Duren, Halsey #I
This t°Stub"to be kept by person issuing Permit.
BURIAL PERMIT.
1. Name of Deceased.
...............age,. . `'..
2. Place of y
S. Date and Place of Death..,.°J,al,_,.../01A..
�' .................
4. Cause of Death.. ,! - -.. ...............
.. ........................
G. Certified by.. . , . ............
.............................H. D.
6. Undertaker.. . °..