Van Dusen, Norman SWATH ON maw TOE. Forms;
i BURIAL PERMIT .
Name of Town .... idFr tag-
(Viilagel and County.
2•. ....rt (Dated,) (C2 ' 190 8'
The Certificate of Death having been furnished to me, as r uir by the Lawn of this State,permiesimo
is herebygiven for the Burial o
q' f..�. .. � Age.:�i..4�..
(City or
who died at °w°,2Yrefe+4.411 Edmr , in the County : ...
Eon.,. ..... $ the cause of death being.A.`t4IC4...! .. St .....
E Place of Burial...f4(6*i . . ... 6r...44441.1
a Undertaker or son
y per 1
in charge of Burial, ) .. (Signed by) .. • . . ..
(I Residence (Official title