Norton This Ytl Stub"to be kept by person issuing Permit.
13URIA.L 'PER.�I}V�IIT.
1. 'Name of Deceased. . 4 .
.11ge,.
2. 'Place of Burial....�i.44. .Too
8. Date and Place of heath...
.. .. .......... . .. ... .!l�
1. Cause of Death.. .
......
6. Certifies`by. . ...
,.ff. D.
S. Undertaker.