Loop, Sidney B /QC.4 2.a
This"Stub"to be kept by person issuing Permit.
BURIAL— PERMIT.
1. Name of Deceased--,aG4T/Al ..
. Placo.of Burial. ,/la .. ..
S. hate and Place ofDeaa.....
. Cause of Deat3a. 1!�'.� c,4A.
.- ,�a.'
6. Certified Ly. ..� .
......................................................ff. A
6. Undertake .t'frr?&W. .S ..t7 .•.