Moulton, John This"Stub"to be kept person issuing Permit.
BURIAL PERMIT.
.1. Name of Deceased.. . A.4-.
............... ...... ... ....I......4de,..(.. .
A2. Place of Burial.. , .,? .
S. hate and Place of Death....w �t
... ... r,t. . .....
lee
4. Cause of Death..,.,. .
.........................................................
6. Certified by..., �..
. .
.............. .. ................ .ff. h:
G. Undertaker