Smith, Inza G I
FR S o EW
a 13 V R I p E R .L9'Jf.. Ir-r w tj4
� - t
Name of To L-�-
(Village) and�i •+.r.ww.awtsww.awywe.w.«.
....«............1901,
The Certificate of death ha vi een furnishe to are s euired b +euurs of this mate,perrtzission
k is hereby given or the Burial of.. .`'. c '�.`� 04
fY'crra .. .
who died at. , 'n the County of.. ........
on. 190 , thee use of death`beang.« ... ..«.«....:I
45i-
Pace of Eurial .....................................
Undertaker or person
64tevin charge 4ofrial, (Signed by). �.
l Residence. ...... ..k� ......... ..... (Uffiew title.)