Van Dusen, Henry sgrAiLlo ow NEW rum,
Form b.
m
BURIAL P H; RMI 'T .
c Vwi an wn
nty. •• ••
.Q (Dated,) /g 190/47
Th,e Certificate of Death having b en furnished to e, as re uired by the Laws of this State,permission
is hereby i qqven for the Burial Age%49.c (City orTownship.)
who died at .. , in the County o .. .. ....... .. ... .. .........
Ott z-4 - -'•f. ......190 ; the cause of death being....46
£ ` Place of Burial..
a '
Undertaker or person
in charge of Burial, • • • • (Signed by) 1.. .. .
r �� ,�
Residence.... :�' ����'f'•�
' r /y (offiefat title.)