Chase, Eucuca Form 6.
P STATE Off' NEW !®SITL.
2 dta vt BURIAL PE+ RMIfT .
+�' � � g�Qame of Town }::... . ..._. :*r�._ ll .. .,.
(PSC88ei and County. _
o (Dated,) . �" �19, '
4 Certificate of Death having••n furnished to me,as required by the Laws of tugL ,
C �--^_'+'- _ ' -•.ate"a
a is aereby given or the Burial of
-
E (City • )
o who died at '���` '`�- `' , in the Count .;�t.�/ :::•-
a./ t .. .....1904 the cause of death being
E Place of Burial(. . . !
-
Undertaker or son 1
der . . .. A ned .
in charge of Bu _ 9 by)...�.. ���+..,,