Lauder, Maggie B �s
Form 5.�
S'TAT� Q�' N�'�✓''W/ Y O F�K.
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BURIAL,,PERMIT.
Toga (Vi ge) of Fort Edward, Washington County.,:.....`.. ........ s
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The Certificate of Death having been furnished to me as required by the Laws of this State,
,� . ...: .. ..:. :. :. ... .. ...
permission is hereby given for the Burial ref:..... . �., .. ........ . ... . ...
e ,,,, ,, ;: ...cha died at Town (Vilge) of Fart Edward,in the'County of Washington, 4
on... x r ...........189 , the cause of death being.... • ; ;��.: . .. .. r. ,
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Place of Burial. .<,.. . .. r-
17
Undertaker or person
in charge ofBu
Burial. . . (Signed).......... . .. ,
Residence. " .... `i . . . .' t. i ... . ........... .... s
(t�ffleial titie.�
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