Mason, Harriet C dw t?/
This"Stub"to be kept by person issuing Permit.
BURIAL PERMIT.
J. Nafhe of Deceased. .. . .... ....... .. ..
..............................................Age,..... »
°L. Place of Burial... ... . ... ....... .
3. Date and Place of Death.... C..
•............. • .... ..:�..`.... ........ •.
. Cause of Death. ......
...............................................................
5, Certified by... ...:....:.............. ;.
...................................................... D.
6. Undertaker. .. .....