Gates, Lovica Form 5.
STATE Off' W 1'
.
To
BURIAL PERMIT .
Oti
to
.:,
o Name of Town ... T? !a
r (V�lagel and County.j'
(Dated, . . . �. ...:%190?
The Certificate of Death having been furnished to me, as required by the Laws of this State,permission
Eis hereby given for t7ie Burial of.... . . .. .. .dge.4.4:::t Z--
o (City c*1 o b&p) •.
who died at 14 -t4r , tin the County of.. .
.. I ,
Eon. . . ./..�jtL....[1..190 Q, the cause of death being Zer:672.tes.4.. .. .
.-.
-E .Place of Burial.. . ... ........f. -4Gj
y Undertaker orparson j .L.44,404 Y4ignedby) •
. ..... .... ....... ..«.... ..
I .
Residence �� - �,.f. . � ��
b �{� (Official tide.)
CST.