Mosher, Louis This"Stub" to be kept by perinin issuing Permit.
BURIAL PERMIT
1. Name of Deceased-,Ct-..eta,-Z--.-!M --��
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------------- —-—-------------------------------------
Sex..,.-.o j .... Age,-3-1---------------------
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2. Place OJ Buri41-63A—A �— —-----e4 A.".4-
Date and Place of Death �---------
2-:$--------------
------
-----------
- --- -------------
4. Cause of Death....:�., -.- 4,
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Certified by.. .... ------- --------------------
---------------------------- ---------------------------------------------------,M. D.
6. Undertaker..._:!ku--1411ra -----------—........
Sold by C. E. HOUGHTALING,Law Blank Publisher,Albany, N. Y.