Roseuberg, Dora h
ATE i �° • _
BTJ IAT;f PERMIT . 4Y
p Name of-Town - .
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and County.�... ... .:... .... .. t
."�+ (Dated,).. L I... w A
2 he Certificate of Death hav' en rntshe #o me, as required Ly the Laws 0 this state,permission
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O irt, �. .JR. ..t�E... �#1 At the cause o deat1i being 7JfNL. . . . ff
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