Unknown 4 ST±A7cE **- lt*W TOM
00 � l.,t-;. -.I A _L F E � a v I I:Tr '
o ff Name of`Sown (�e -. '
,-. t(V stage)and County ij
44
l-L (Dated) .-- =s�-.- -•--_...,::.:.II)/
1 ` The Certificate of Death !saving been furnished to me, as required by the Laws of this State,
permission"is hereby given for the Burial of _ - -_ .,_._,elge
o - (City or Town <iP) - , .
who died at _.} an the.County of..y 2 =
on ern,., /J 19/4 the cause of death being-- - r 4- .,.... ..._..,....,..._,
Place of Burial
Undertaker.or person ZdL &.
ofBuril `-'`- -- (Sgnedby)
Residence- -
(ET#'Picfat'htte:)
c r �_
y g 'j
BUR1AL'iflE'R IT t
a �,. .,
, , N[�,nC„?. ,, ee 4d , , , , ,
fir' , •x i-,.v d
.l w1b r r / 11 _ _
k �. / k,j y
...,„,,,,,,,:,,,10 . , , ,..
, ' , s
- ,-------, ,, -.--,---;----------. -
I i,
,., - ,
(,,, ,, ,, I ,,:- ,-,,, , , :, ,
„ , , ,:, ,,,,
III t ,e` owll(Vi1�a v ty .
County off ... 4 '
t a rr• ;
.
y
ry,
NOT$. »'I'bis permit lSxonlysto„be railed fora
burial wifhin the county''yrh ere,the death t i eg
pl-ce,and is to, kept by'the cemetery keeper
where tie body is buried. It is to be iSaue#i.on
the filing of a death certificate,certified to as
r hired by Scq.`2. oo Chapter'661,L*^ws of 1,98.
,"r - NoTE:-Buri l Per 1ts�;and''all'Blanks are to
be procured s ,'Town aid V iiage Clerks nd
' Boards. of walth.for the Registry of Bi.arths,
Mari'}ages, T.l'ehths aad,Burials. '