Coffie, Jessica NEW YOUR* Farm 5.
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o Name of Toevn; %( ..=
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(MaBel'andCounty. ..�«:«::h: ;. '. ..
-Q ...... .(Dated,). ..04-r ..�6.19oi.
.
T1w Cwrtocate of.Death having been furnished to me, as required by the Lagos of this ade,,permassavn
CL is'hereby iven or the Burial of
o (City or a
who died at.. ... in the G'ounty of...a
..<.�t�'t..l�►s�,�!„�. .
......1901; the causek of death being. ... ,�¢ ;, ,
�. . ........... ..
Place of Burial..
w ! Undertaker or son
..... Si ned b ... ..f in charge of�,, al, ( 9 y).' .. ..........►...................j
Residence.. ..:�C.. .. ....... .