Smith, Leonard Forms.
S@VAWIC OF NEW TORK&
JBTTRI -& E P -i M T- .
co
45 Name of Town
" (VIDue) and County.
.(Bated,}. .... / 190
The Certificate of Beath having ben furnished tome, as required by the Laws of this,Mate,permission
E l is hereby given ar the B t of.. ..,, ...:�!�.. ....... ....►. ...�ge,��
€City or ownsinp.) ("
who died at.. ......'. ti.<-C,,C?�.,.. . .,...... 'n the Baunty of..
1?on.,.... . ..19 cause of death`being �..,.,, . j
Place of.Burial.... . ........... ...... ...............
Undertaker or person . ..... . .... .. (Signed
in charge of urial, f
Residence. ..t� :` ::,, ,r}�,« ` (oxQiaititle
L�l