Hersey, Alice N e s
I3NameofTown
"' RIAL PERMIT .
* (VUlagel -d QO-ty ..... ..................... .. ..... .,.» �.
. .dated,}. fl'.. ♦ ..•...•.i.. ♦.. .
............. ........:.. .,...,. ......,.... . .aa.. ,;.
The Certificate of.:heath having been urnished to ine, as required by the Laws v,f this Mate,permission
is hereby given or the Ur of.. .....,E.. .. `
0 1 (Oltg or o .} ....... g
who died at. ., in the county af». ...�'. .......... .,.. , .
on.. £ } the cause of death being.. ... .... .............................
`p- P2ace,of Burial..
Undertaker or ersora le
. ... ....... .. .........
� pp {Signed by).
in charge of b'z�rtiaZ .• �... . "' • .
. . . .�... . ..
W Residence......................................................... ....... . ...
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