Russell, Lila SPEA9M1 ON Irmw TS ' Forms.
BURIAL PERMIT .
Name oP Town' i. ..4,44 �/ ]►J
cvniNaeel and Conn .} �JGC'!'-
- y
...(Dated,) l� 190:
The Certificate of Death having been furnished to me, as required by the Laws of this State,permissiog
is hereby
en or the.Bu l of st jbwnship. .Z u {R::t:.l f. .... . . ..•— .....Age &
g who died at a !� in the Caunty of s.fl ...,•.
Le/ ll! T90�,the cause of death being �� K.:�:�1 /: „.:`
E Place of Burial .mot....
° ZTndertaker or i• son- L- ..-
s in charge of rid,. etf.,,&...a,...,c.... `(Signed by). " ,/3• ..
�Lesidence.. , %.4,ez
.
`% / � (official title.