Elinr, Dewitt Clinton SWAWN OF NEW YOUR* Form,5.
M IA L P _ER M = A
1
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o Name of Town #/ G
(Villagel and County. '
a ...............................................(-Dated,) `.............I89
.The Certificate of.Death having been furnished to me, as required by the Laws of this state,permission I`
is fiErEby yivEn for the Burtia of...... -w ..�.....? . E
(Glty or Township.) �---
who died at. � `������ - in the County a ................. l�
an. . .� .189-the cause of death
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............................................................
Place of.Burial.
ICA
Undertaker or per son k
g f �.... ........:.......
=_ in ehar E o Burial ...... {S'' € by ... .�... �.. ........:...............
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...PLESidEnCE. J: .......................
(Officw titie<)