Lacotte, Amella This"Stub" to be kept by person issuing Permit.
BURIAL PERMIT
1. Name of Deceased_.._.-- 1-�-- - ---------------------
----------------------------
Sex--..�.Ls-..s.
Race qj Burial--S-r.---
8. Date and Race of Death----- ----------------
-.4t
Cause of Death—Z-4,61 law
..........I ...... -----------...----------- ------------------------------------
5. Certified byj.f..J�,
.....- — 1� ...........................
--------------------------------------
----------- .......... D.
6. Undertaker_.... -------
Sold by C. E. HOUGHTALING,Law Blank Publisher,Albany,N. Y.