De Grush, Catherine This"Stub"to be kept by person issuing P
BURIAL. PERMIT.
1. Name of Deceased.C,ak.� .......
......
R. Place of Burial.. ...�.., &4—, A...10—t�
8. Date and Place of Death. Q., .....L 1,11-
4. Qduse.of Deata
.......
6. Certified by.. t.Y VN.. .
6. TIndertaker.tN\: .,. ... �.,