Brayton, George W Form 5.
P eggrayirs ow N3SW Y
BTJRIAL PERMIT .
oo-; Name of Town tt , tret�k� �a��
l(Vfllagei and County.f tiL
' , (Dated,).,... 190
rtt cat�$ Death havin been furnished
to me, as r aired the La =t te,permission
. � f e4 bJ
Iis hereby venom f. .. ... ..... �, .. .:.dge
who died at .. , in County.of. '." .• ....•
.. .40 it . ..19Qy; the cause of death being,.. . . ° y. .,.
P '8 7 •.. . .... .• .
w fTndertaker �ersarc � ff�lt igned by).. .. .�.in charge of B •• ••
b (I.Residence4-