Witherell, Henry :� Farm b
�a SN OW NIRW R*
41
RVR 'A PERMIT .
Wame of Town
.. ... ...............
+ (village) and County.}
................................................(Dated,). .. ................190
'H fibs Certificate of Beath having been urnished to me, as requir by the of this State,permission
is hereb y gieaa or the&urial of.. f .. ...d ye. �
a (City or wnsriup) .. .
..
who died at, .. .4. .. , in the County of....... ««.
an.. 1 0/` the cause ofdeath bein . ..... . f.s.......................
,.
` f uriaZ..
Zik
V ndert Or or Orson
f
p ......... ........ ........ (,Sign ....... ....... . ..... ....
in charge of Burial ..•.
`. y a tirxe......Residence. `% �?