Black, Calvin H This"Stub" to be kept by person issuip Permit.
BURIAL PERMIT
1. Name of Deceased.0 t t[Wit.-�- -_:----_--
- -I -- x --------- -------.... -- ---------------------
Se
2. Place o}Burial---S-* --- - -
8. Date and Place of Death
4. Cause of Death .. --
6. Certified by.. .-�.............._.....
---- - -- ----- -- -- .......—..--M. D.
6. Undertaker----------------------- -------: I------------------------
Sold by.C. E. HOUGHTALING,Law Blank Publisher,Albany,N.Y.