Chadwick, A l Form
ATE Or T
r. BURIAL PERMIT .
Name of Town i �. .. . ..................
'
(riitagel and County.7
-o
(Dated,).. 190 IC—
.a
The Certificate of Death having been furnished to me, as require by the Laws of th' State,permission
is hereby given for the Burial of.. �r
c (City or was •. •... .Age, .
who died at �-'� , in the County of •
9'tS =r
on 19O ; the cause o eath being . ... ..........
Pl of BurialO '
o
Undertaker or arson t� ai (gigne
in charge of r' 1, C ! .......
Residence
( ffietal titer}