Bates, Lester MW WR OF NEW Y *
Form 5
Co
I3TTRIAL PERMIT .
Name of Town .................. .....: . ....(Village) andCountg • ••••• ••••••••
o "" c .(Dated.).. "'
The Certificate of Death havingn furnished to ane, required by the Laws of this State,permission
Ois hereby given-for°the Burial af..r�c�...... ..... . . .. .?... ..... ..................14ge..
o (CityorT 'p} t' F.
Co who died at.................... ::.................: ....... ............... .. in the County of. .............. �.
on..... .... .......IV ; t a ause of death being.. ... ...: .:.:...
E Place of Burial..:.. ,` a..,.� ,� C " ...
Undertaker or person I . .. . �t :. - 2;cc c.
.& -�'-
in charge of 'ial,�, __ (Signed b'
Residence.....-:.. :.............. ......... ... •
fficial title.)
p