Dunsmore, Elsbie SIVAWN OF NEW WORM,
Form 5.
�y
E P ..ice R M i T .
m
c (( Name oP Town. { 3` ... ..;F4,t I
ZO 2(Viiiaget and County.
c" A4 .n.........(Dated,)... ...f........ c
The Certificate of Death having been furnished to me, as required by the Laws of this Slate,permission
is hereby givenor the Burial of ..
cI (City or 0 .... ..... ...... ...... .... ......... .. .. .............
CISwho died at.. .. . ....... .. .. ... he County of.... `
t
on. y.-.......*�-, �. -Y the cause of death being. .... ...... .r.
9 Place of Burial.. "` ..CL
� .• �'
Undertaker or person
s in charge of Burial, """' . Signed by)....... ..........:......
Lh .............
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