Gifford, Alonza —
This"Stab"to be kept by person issuing Permit_
BURIAL PERMIT.
1. Name of Deceased. .: .......
X4*�* ei
2. Place of Burial.. ..
S. Date and Place of Death.. !?h.►.. /.1►..;
........ .. .. '' "'".......
4. Cause of Death.i .... .. .....
6. Certified by.... 1!Mr-y,s .t, ................
..................... .H.. D.
6. FIndertaker.. u—
Form 5.
A ow E T
BURIAL PERMIT .
Name 11 Town (( . R1 r1 wa.. V <;� ei •
', (Pillagel and County s •• ••• !
0 �C�C�/a sc......b:rtcl (Dated,)(222 .c.t....l& 190 .
The Certificate of Death having been furnished to me, as required by the Laws of this State,permission
is hereby given or the Burial� f of.... . ...
(City or Town ) - )
who died at . . . ...G , in the County of....//{A/�/�/_'$ 2..1rr..,,,
on.S.`!. i.Gt....44.... .� Z9#d the cause of death being..12.Z� .rug..f....IrSirstrarstr
-I Place of Burial..ari2.74
.. ... .�"'f-
Undertaker or person / � � ��—� �,t�
>i. (Signed by) ...1l..:..i'i.:�,tC�r.+..,
7-2 in charge of Burial,
h Residence " --G-1.•.-1, - `. .. ..
t'Y - (Official title.)