Dexter, M 5.
SWAWN OF NEW Y Form
BURJCAL PERMIT .ca
a Name of Town -- a —�: ,, ,d, f —
(Village) and County.t. .
................................................(Dated, / 190
The Certificate of Death having been furnished to me, as equired/by the La s of this State,permission
g- is hereby given.for the Burtial of.,. ..... :.t�.� �!j 2G� - .Age.
. .. ........ .............
v ( ity or Township.} j
! who died at. ........ .. .. ........ .. in the County of..
f on. ..{ 1Gi; the cause of death beiny... :z . . 4
Place ofBurr :?: .. ...... .. .....................
Undertaker or pers
. Sed in charge o (sign
... . .
I�Residence. ..
-.... . ... .( fficrlaZ title.)