Traver This"Stub"to be kept by perwn issuing Permit.
BURIAL, PERMIT,
1. Name of Deceased ,e t�... ..........
... -!4,•�%t.�c. -,,....................Age /.� ..
2. Place of Burial
S. Date and Place of Death. Clj,......
..:4�. ..... ............
4. Cause of.Death. .,,,t,�/�,-- .....
........
i �,6. Certified by.. ,... �... �......
.................. ....... .........f D.
6. Undertaker..