Mattison, Marauda This i°Stub"to be kept by person uing Permit.
BURIAL PERMIT.
X. Name of
...' }' re,tYr�..............Age,,1J.....
2. Place of Burial... , ...
S. Date and Place of Death...ZIA,1-3..... r
!. Cause of Beath....
.................... ..........
6. Certified by. .`
............ .............................M. D.
6. Undertaker..... v
STATE OE NEW YOUR® Form 5.
m
BURIAL PERMIT .
VJ N �
a }...g........
Named Town
0 j
, _,,,,
!C�'�11age1 and County. ...erfete'r-j • a.„,...._ ceo
,.
(Dated,) M....n.....19a1
The Certificate of Death having been furnished to me, as required by the Laws of this State,permission
I
n- is hereby given or the Burial of �14..4 .1-sf.}�.44r. y�,,
I c (City or wnship.) ...lJ.l..ti-+A.. �P.PYi.. Age... 1..
who died at C� , in the County of...... 41;4�!x.S.Arst--.,
s on....6 . ..3. 19®/; the cause of death being ... .
1 � Place of Bur ... . .. .
d
yUndertaker or person. ay�,,
if in charge ofp,Burial, Signed by) P V • ,,
3 If Residence i1 4r' (4_17 �1cek.P ... Pt - c--CA-7-4
f 1
(Official tine.)