Bates, Royal SWAWE OF NEW WORKa_ Form 5.
I3ITIZIAE PERMIT .
m _
o j Name oP Town
2(ViIIMel and County.S
...(Dated,V& .1V`. .47
,.. dr..
I%e Oerti Feate of Leath having .een furnished to, e as required by the Laois of this State,permission
G -
is on for the Burial of.
ownshtp.)
uio .............................. in the County of.
.. .hG�the c use of death bein i
'9 I Place of Burial ...............
4
Undertaker or ers�
=_ ( in charge of �icrial Signed
. .