Crossaut, Ina This"Stub"to be kept by person issuing Permit.
BURIAL PERMIT.
Y. Name of Deceased..� �
Age ...
°L. Place of Burial. � �x �;:� �� � ��•
k 4
S. Date and Place of
, .
4. Cause of Deatli....._ . � ... �.�:.... ........
g. Certified by .» . `. .. ....
............................................ .....M. D.
6, tTndertaker .. ......
t 03
� F l_ 27> ®------------ ------------ ----
Form5.
#ill i
RIAL PERMIo
T .I T .
o�' t(PitlaSel and County. � �4••;T4 y�/^',;� _........
The Certificate of Death having (Dated,). f
been furnished to me, ""' "79 a
cv is hereby as required by the Laws of
given or the
...
who die (City or hip.)
of �\ � this State,permission
dat...... ............. ..............................Aye e ..
4. .,_.
on.. . i• .: ......... ............................, in the aunty o
.... .........Z.�S the cause f,.�q��� ..
I. . I Place of Burial........ . of death being, . ....: •........
$ s I undertaker or person :................ .............................. ..... ........ ........ ........... .. ...
* f- charge of Burial, f ..............., •... .,.... , n
�y_ (Signed by)...�f),. 1"s.
Residence....�,'�, 5�.. .. ...... ;�;�"�
•....sue..,•-+....•-M--..4**.•• ..--•si fi+a N ,4.—f./Ya.
BURIAL PERMIT.
•
Name of Deceased,
Date of Death,
Cause of Death,
in the Towr4(Village) City of
County of
•
NOTE.—This permit is only to be issued for a
burial within the county where the death takes
place, and is to be kept by the cemetery keeper
where the body is buried. It is to be issued on
the filing of a death certificate,certified to as re,
quired by Sec.23 of Chapter 661,Laws of 1893,
NOTE,—Burial Permits,and all Blanks are to
be procured of Town and Village Clerks and
Boards of Health, for the Registry of Births,
Marriages, Deaths and Burials.