Whittermore, Doris Form
STATE OF NEW YORK.
Pq
IE3URIAL pERMIT .
Name of Town, ............
4- (Village) and Count
(Dated,)
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.,�ed b 7vh e
The Certificate of Death havlv-'�been furnished to ine, as required by e Laws of this State,permissrin is
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hereby give,for the Burial If---- -------------- ---------------
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(City or Township.) in the County . .....
Of.
who died at �gl
41 the cause of death beA
on
Place of
3�
Undertaker or erson
(Signed by). -------- ------
9.n charge of Xuriai, ) I
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(Official Title.)
Residence------- -------------------------
IL