Chardwick, Beatrice May Form&
SWAIM or NEW TOKKO
DTJRI ..& ,L PERMIT .
rtaane of Town
................................................Gated,). . . .........190
The Certificate of Death having. een,furnished to me, as;requir by the Laws of this&do,
is hereby given or the Bursa .. ,..� .,. . ...Aye.
c (city or )
who died at .., in the County ..... ....
C on.. 44-f .. r ...Z90 the E/IS! of death being. •..... ., . . R .{i....l..`......
E Place ofhu'7 W. .:` } . ... ..
Undertaker or�arson
in charge t?f Cftb ...................................«. (Signed ..»... w.y»as.«. .....r..
.Residence.. • .•. .•