Witherill, Delos F SPATZ OW sinew 1r Form S.
BURIAL PERMIT
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o 1(VNmge ):Toownu nty.�� •
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L�Gc.ur.... :..�,7: ,.. .(Dated,)....45 : .v�- l7 19011.
The Certificate of Death having been fur fished me, as required by the Laws of this State,permission
eu is hereby given for the Burial of ��' fed... . . . , . .Age.�f..:� ..
c ( or ' /t
who died at Wree- . ~— , in the Count o "�`
on.. // ....190g the cause!!o death being
Place of Burial... : •t?r •-•• < .. . • . . . •• ..•
Undertaker or g�•son —
s I in charge of Bu °ad, f 7- • 171.(Signed by).....-)4••&.
h_ Residence — .) (Official
tt e
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