Inuitle, Joseph L Form.S.
SPATE OW Riff, T®n*.
`. BTTR IAL PERM T .
c i 4.7,e onTwonm ty.ii
3 (.Dated,). . /.. .'�. .....l90ft
4,
1 The Certificate'of Death ha been furished me, required by the Lagoa of this State,permission
a3. J
°' is hereby given or the Burial of., .... . ... ..A.. .. ......tlge A
a. Chi' ,/
c or '.
who died at .... , in Oounty of. . ........ .. . ....
Moo.. 190 t cause of dearth being ''' I
I
E Place of Burial.... 1
Y
undertake?'or pesor
in charge of rrno; (Signed by .:„.„ I
Reside .. ..•� �� w•�•• (OfficialMe.)