Van Dusen, Harvey or NEW WORKS
m=t
.� Name of Tawn
(Vfflage} and County. •
................................................(hated,). ..`.:::':'::. . •190
The Certificate of Death having en furnished4. ,.
as required bg the Laws'of this�S`tate,per7nissen
is hereby given or the B ial of. :. . .. ...f *Age*
' (City or Tawnshig.)
who died t. .:r.4r. in the County of.
on.. .. .. 1D the cause of death being.., ..
.......ti...
jPlace of Burial.. ... ,
I Undertaker or person .
f Bur' (Signed bg}.in charge o -it,lalvwl......
Residence. .......: :.::.