J P SWAWN V Y Ire . i
: IT R IAL " ERMIT .
all
Name of Town
illaget and Connty t.............................. ...... .............. . ...<,........... .........
...............................................(Dated,).. . G� 190
Ae Cerlifwaloof.Reath having beery fur 'sheet o me, as re trod by the La it of this State,per aission
is hereby qaver for the.Burial of
{ ityor To
arrTxo coed at .................. ire the GTounty o
on, ..190 the eau of death being. .. .....................
Undertaker or person . .
in charge of.Burial, . (�Szgned by}.
�iesiClen..
€I �{Official title.}