Howe, Clark Form 6
BTTRIAL ER IT .
67
:,_.
G Name of Town ... -....
*' (Pillager and County. '
v
(Dated,)- `7 d90
The Certificate;of Death havin e fur s -d t:, e, as j equir d the Laws of this State,perm sion
is hereby given for tree ' d of.. ..... .:. ... Age
o (City or wnship.)
who died atCZ , in,the County .... . ..
w r�-1 V-
on...s. Z90 ; the- cause of Bath being 74%'i""""'4... ... ,
Place of Burial
a Undertaker or person
.: in charge of Bu `al, (Signed by) i
Residence . . . \ge-771i
-o- (official title.;