Dunsmere, Alexander x
_ -- --- ------- Form 5.
---- �130 Or NEW O Ko
;I PERMIT •
m
13TTRIA ,
Name of"Town .... .. ..... ... rF
. ..
o (VillaBel and County
o {Dated,}... .... ?.....189
y The Certificate of Death having been furnished to me, as required by th Laws,of this State,permission
o is hereby Civcn or th
e Burial o •. h,�! Inge.
c I (City or o.... p.� .......
t`�c c r , in the County 0 '�`'i
who died at..... .. ......
'`,,,,....189 5�;_the cause of death being.. • • ..... . ........'"..
Plac�qf Burial..
Undertaker or person .. ..... . (Signed b
in charge of Buria y) � ,yr ,
:) . ..,.
Residence.
........ (Official