Alley, Clarissa Farm 5
OF NNW K®
L TTRIAZ PERMIT .
o blame o and
Cou .y .... .. ..fir:.!fir !. ... . �
(Viliaget and Conntg�" •«:
................................................
The Certificate of Death having bee furnished to rre, as re aired by the aus of this State,permission
is hereby given ffar the Burial of. �
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who died at.. _ in the county of... ... «... .
on. . t��90L; the cause of death being.:. _ ..«« ....«. ... .E:"....
..1....
Plaee of urial.. , j .!`?
ci
Undertaker or person ««..« «««« « .«.. ,Si ned b
` in charge of Buri 1, . . «. .. ( g y}«...1. : .,.. ... .«« a ....«...««
..
li'esidenee. ��. «
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