Bates, Maurice AWN OF * '
P. MIT .
m
c Name of Town
+Yt' (Ve) and County ....... . . ........ . .........7'y.......... ..1...... .f «.+/. ...s w.. c�.1/x
Dated,}. .. itf.ff ... . '/V
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{ T1w Certificate of Death.having been furnished to we re ny the Laws of this State,permission
is hereby given or t?e Burial of.. .�.. �t.... ....Age, .
�. 0 (01ty . ........ ..
who died at , ' he County of
y �r� «
pryb,. { the'YCa2G36 of dead being.. .. ... .... :. ........ e....«..sir...........
Place of b'uria .�..
Undertaker or person
in charge of B iaZ . .......... ... .. .. ... .,x Signed . ..................
esidence..R t ..........
f�