Van Duzen, Bethuel u
;a
Form S.
03F NEW
rM
BTJRIAL PERMIT . r
Name of Town
1(Z'}}tage) and(>rl ty
-�; „ • ..... .(Dated,
,.,
fibs Certificate of Death having been urnis hege
d to me, as required y the La this Stats,permission
is hereby given for the Burial o .
c (City or Township. + ..
who died at. the Count o
y 189 ;—the cause o` eath being.CIS
......................
on ce o Burial
f r '
Undertaker or person igned by ... '
s in charge of Burial, ---
~ (o e title.)
Residence. '