Sherman, Violet This"Stub" to be kept by person issuing Permit-
BURIAL PERMIT
1. Name of Deceased--�A:Ota--`-�-
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2 Place of Burial---
8. Date and Place of Death-- L----------------
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------------------------------------ ---------�*-- --
4. cause of Death,
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5. Certified by.....el.-rw, ga..zl-n--------------.......
---------------------- --------- -------------------------------------M. D.
6. Undertaker-& 0-.^------- ...............
Sold by C. E. HOUGHTALING,Law Blank Publisher,Albany,N. Y.