Van Dusen, R r— z —
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;WAIN �'F 1'E W T , 3Ml a co Form 5.
•
BURIAL PERMIT .
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Name To j
• " (Villagel of and Cownunty.I ....
(Dated,)Z 4 tom— 12.4...1907
The Certificate of Death havin been furnished to me, as requ'red by the Laws of this State,permission
E is hereby given or the Burial of L �-c• Age, 4�' o. /
who died at Y'�� S' , in the Count of
on...fP.W Z ,..190 the cause of death being . . .•• ,••.•••
�,�
•
s Place of Burial...: /r'� ,
• ;, j
• 0_, Undertaker or person G(/ Sined b
in charge of Burial, q y).... A...., .. . ...i .,p-
1
Residence
(Official title.