Rickitts, Jimmie SWAMIS OW.NEW Forms.
BURIAac, L ` P RM T .
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c Mama of Town 1 b ...
. ,(Yluagel and County.f
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(Dated,)... . . . .:. 190
The Certificate of Death havi been furnished to me, as d by he La of this State, fission
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a is hereby given or the al of. . 464-ff
.....71 :... .Age. ,t
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c (City or
who died at the Count a
gon....✓ .q 190 the ea of death being ... .. ...�' . . . ...
Place of$ ... .. "
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Undertaker or�►arson b
: in charge of Bu ° 1, .. . .. (Signed y)... .. aide j I.
hResidence. (o>adat title