Gifford, Hannah SWAWM OF NEW WORK* Form S.
13 T-T R I -A- In P -E MIT .
Name ofTown .....
(VIIIage) and County.
................................................(Dated,)..
....... .....19041,
YWe Certificate of Death having been furnished to me, as required by the Laws of this State,permission
e Burial f...is hereby given for the .............. Agel�
o (City or Tow
. ....... .....
who died at. . ........ ...... .................. ............... in the county of . . ....... . .......
on... �90 47he cause.of death bein .. ....... C, V
ial. : ......V.
. . . . .. ... . ...........................
Place off Bu
Undertaker or pe®rson, . ........ ..
..... .
in Charge of Burial by) .....................
Residence ......................... ..............
........ ..I.............................. .