Dean, Mary Form 5.
SWAIV,30 OF NEW YORK*
113 TET R I -A E P -E -R M Ism
IName of Town
(Vfflagel and County.
...........................
............190 /
Y'he Certificate of Death having been furnished to me, as required by the Laws of this State,permtsszon
. .. .... .............................................
is hereby given for the Burial of....
(City or Township.)
CI who died at ........................................................................ in the County 0 ... ............
..........
E oW`....a--4--0--_6....................1905 the cause of death being.. ... ... . ... ...........
Placeof ............ ........... .......................
ndertaker or r.
U 4��
(Signed by).......C.,
in charge of Burial, ..................
Reside . ......
Residence. ...... .............
(official title.)