Lockhart, Edward Form 5
SWR OF NEW WORKS
BT.TRIAL PERMIT .
m
o Name of Town # � .. ........ s!h:t?� �Z.�"," /,��_ � Lf
*� ' magel and County. .....Y.:..:.f.Y.....r:+:
....... ........ .........................(Dated)
The Certificate of Death having been furnished to me as required by the Laws of this State,permission
a. is hereby given ar the Burial of.... ����`a?t�! i�� �:44<'�� ..�....................�ge,4�s�:�: �,.*
c (City or� hip)
who died at.....................' �.... ................................. in the County
.......... the cause of death beinZ. ,
...... ...........
Place of Burial.... .... . � .. . .. ....
Undertaker or person
s
in charge of.Burial, � ...........i`.:......... (SignedAl.Lh I Residence............ .................................... -.x......... tit}s.)