Smith, Mary A This"Stub"to be kept by person issuing Permit.
BURIAL PERMIT.
1. Name of Deceased. !l '.
2'. Placs of Burial,M.t.w..A!!k,—�°`�.
. .Date and Place of
1
Cause o .Death... .�
....*.
Certified by..
.......................................................
................. ....M. .D.
6. Undertaker. �..
P ®TAM OW NEW T ® Forms.I
BURIAL PERMIT .
0.
- Name of Town. I Off!�';•• • L
. iAagel and County.f ,Ap �
cif!'. . . �--ot (Dated,). ...: .J 1900
Ja
d
The Certificate of Death having been furnished to me, as required by the Laws of this State,permission
Q- is hereby given for the Burial of...011 .....,d9.Yi„t.. A ..
o (City or wnship. j,,_ g
who died at .. .. . .. .. .. . , in the County of... .air '
y
on 7..3 .199,0 the cause o death being /''/
Place of Burial...01C—t ..a.
Undertaker or Person
4. in charge of Burial, (Signed by) .... .., ..
Residence.. . . .. ..... 2C """— ....
(Official title