Chase, Edna Pearl Form 5.
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71
1U- RIAL . P RM T •
cown' I L'F sei°aEnd County.} ... ..
.a (Dated,), 190
The certificattepeavi-ho,• , ier urn o me, as requi d ,(ttigt8 ,,r,�,n ,. ;
I ' is hereby given or.tlio B rail o 4®. ' r ... _ ,°
41' EYor .f� � r. 4c'r .�s+� I
who ai as:. ram: l'
.. . , the �'oun o ........: .., .:�..
Eon.. 1......390 ,•the cause of death being • . .... . . . .... +. ....,..
'E Flace,of uiial.. • .....
V
I
ITndertaker or arson
r 1 in charge of uraal, (,Signed by) :z ..»...
ii .,Residence. 4. ...
. . .... . .
it
(0fildal title.)'