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Smith, Byron J
A OW W Tows.. Form s `E BTTRIA PERMIT -- o S Nam o4 Town OA Fc (Qjitageel and County� y tJ�� v -34 (Dated,).. .� 190 C The Certificate of Death havin been furnished me, as required by the Laws of this State,,permission `° is herebyaver or the Burial a. 9� of Age.�Q. who died at or F �'� , in the County. on. ./a.. - .2c .190* the cause of death being /iy,f,tdz.• ... . ... . . P. ;.., • Place of Burial. 4! 7L' i Undertaker or person /1G'/(J//J�►///_/ �l© (Signed . in charge of Burial, by) •.. .� . } it .Residence (eattnee.)