Rose This"Stub"to be kept by person issuing Permit
BURIAL PERMIT.
1. Name of Deceased. dam= ......... .
G. Place of Burial..... a.
8. Date and Place of Death.. � 1 4
I. Cause of Death. . . .
.... .........11................................................
6. Certified by. f). "J s j. . ...... . ..... .. .
........................................ A
6. *Undertaker.