Close, Robert This`°Stub"to be kept by person issuing Permit.
BURIAL PER—MIT.
I. Name of Deceased . .............................
............................................Age,...3.
Place of Burial...C .. _,..... ......
S. Date and Place of Death.
. .: f. .,.. ...............
J1. Cause of Death3. ..........
..... ..,.
.........................................................
5. Certified bg. ........
......................................................
6. Undertaker.... .