Unknown This"Stub^ to be kelof by person issuing Permit.
BURIAL, PERMIT
X. Name of Deceased. - - --------------
—- -------------.--__._--------------------------------------------------------= -
Sex.. ---- -------- ...... AR er -
2. Place of Burial- - ---- -
S. Date and Place of Death-__ -__ _...T!tL -
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__- ,�- --- ----..... --••------
. Cause of Death... --------
6. Cerfi d b fie y_ � ''..._.: �.�a���
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6. Undertakers
Sold by C. E. NOUGBTALING,Law Blank Publisher,Albany, N. Y.
Form 5%
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u. BURIAL. PERMIT. '
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O r e o { Name of Town +lY_�eS.!-2!LR -i� a — at
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4 "= o t/Y 't1``k. -- � __.(Dated,).. ' - -7 /0 19 1171
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V t 2 The Certificate of Death having been furnished to me, as required by the Laws of this State,
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c�?s permission is hereby given for the Burial of_-----ZM4Y?'lt^
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� o o (( (City or Towoahip)
d 0- 23 Sex'Y1ti�. Age-_._-xK • who died at__.c� 111- wn.hipc� , in the
a co
W pia S County of — on 69 f 19/i•the cause
0 •tt m a o +' of death being"". - .4 1 Place of Burial"-_ _ee
Undertaker or person Q __ _
XYl _�t_ _ _ � j (Signed by)�h _- ----
o 'tt h;a I' in charge of Burial, 1 [ � � �- { -
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q V) i s Residence v. ...,-.0 = a-- -� (ovsx) (Official Title)