Jenkins, Clark WN or NEW YOUNS
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13 -URIA- E PERMIT .
o Name of Town :(Vila8et and County. ......................
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sai .(.dated,). '� ` . 90
Tlie `ertifieate of Death having be f rnish to xre, as required by the Laws of this State,permission
is hereby given or the Bu ict of.. � �
o (City or o—IbdIp.) f ' '� sr•. g8.1 .,r'(
who died at.. .. t :�. � �, r� � # , in the County 0f..
on. ...1 .....19f1 the cause of deat7a . ...
... ..
E Place of Bgmal : . .;.4 : .
, Undertaker or persan .� �� �
I in charge of Bur 1, (Sign �� . c: ::..: ...,... -9...,,.
_Residence. .. . . .... ..........