Lockheart, J W * Form&
L 1 -URIA- E PERMIT .
m
o Name of Town
i(Village) and County.j '—
s ............................................
................................................
The Certificate of Death having been furnished to me, as required,by the Laws of thj8 State,permission
is hereby givenor the Burial of.. .. �,:-:!L
o (City or o }
who died at. �.., ... .............. .. tin the County of...
€ on... ..... 't. `. Z 189�the cause of death being.. ....
Place of Burial..,.... .,
... .,
a i Undertaker or person .
in charge of Burial, . . .... ( iy by) ...... ,� ...... ....
...ram•'" •. . .
; Residence ............................ ............. ..... ..:.......... ... .. ....
(official title.)