Stewart, Fanny J Thil«Stub"to be kept by Persan issuing Permit
$'(,.TRIA.L PERMIT.
Deceased ' ........
1. Name of (� ��
Age, 2�
Place of Buriala '� ,r
S. Date and Place of Death..
4. Cause of.Death.
....:.....
6. Certified
.........H.. D.
6. Z7ndertaker +�. '' �� �