Smith, Lois This"Stub,'to be kept by person USWng Permit.
BURIAL. PERMIT.
t. Name of Deceased. ..,,. .VV4 fir!.....
Age,. IL
0. Place of Buxial. ..
. hate and Place of heath..` t... .. .
. Cause ofDeath.
S. Cergfied b . „ . .
.. '. .,tit. 11.
pi 1 Form 5 i
r I 0 TATE 4DF NEW YOUR*
Tcs
-, -R ITIZIA_ 1_, PERMIT .
....-
. 1 07 pTagme oafjdocwonunty.;.
c:::;171-4.--4-.06.,:a.-.•....4.•..•
>,
(Dated,) ./)"''''I 4/ /90,./
..0
_.
The Certificate of Death having been furnished to me, as required by the Laws of this State,permission
is CI.. t hereby given for the Burial of.... /.1.-4....e.,,,,,.......
Qatgar-TzTp.
° who died at
Cd , in the County of eri2-1v-i--1---s-•-.... .
4e- r E on 4 -3r i _alb the cause of death being.
:.-.
E Place of Burial..
a_
Undertaker or persurion i I -4614..e.A'',. (Signed y in charge of Bal,
h
11-4- ._Residence --1(-- ,,,,,. .., r
75:0*-4-14r-r4 4 r, "----%:4 4:44.......4,....J....
(Official title.)