Mondeaux, Autoine This"Stub" to be kept by person issuing Permit.
BURIAL PERMIT
1. Name of Deceased---—- --------- -------------
----------_-----------4:aYN.C'-Y_%_.CL&.eA�----------
...... Agt,......4_1
2. Place of Burial fA__ale�sll�----
8. Date and Place of Death------------------------
- ---- --------
-------------------
4. Cause of DeathuLo�-Q�----
------------------------------------*1111----------------------------------------------------------
5. Certified by.�,. ... �_. l. .........................
-------------_------------------- ---------------------------_-------------M D.
6. Undertaker__
Sold by C. E. HOUGHTALING,Law Blank Publisher, Albany, N. Y.