Van Dusen, Sally 1
I 1 P ,J,Awirl JP NEW YORK® Form 5.
71 BURIAL P 1-1. RMIT .
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The Certificate of Death having een furnished to me, as required by the ws of this State,permission
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,a.., ,is hereby given for the Burial of.... 71/( /Uc4. VG .1
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714)111- 1, —,
who died at
, in the Oounty of
l.0 on 71/14/ aC,17L 1909; the cause of death being
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i 1 fli22:cleherat ra gkeeroforBpiterriso,n!. 21....
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1 4ir'7,t11,t1 ‘--6e121'et,It Residence
(Official title.)
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