Van Dusen, Warren au ATE OF TOWN. &
BURIAL PERMIT .
»� ame oP Town ... 'S�Z 4t`� "'. — "S
1 1 and County.} :..
v
(Dated,)..i . . .n11i#4
The Certificate of Death having been furnished to me, as required by the Lava"of this State,permission
G
fl. is hereby given for thI Burial of... J. �� . . ; Age 2:::47 e5
who died(at o. _ .. 4f-ezer- .... , in the Count o
uy .f
w -
E on.....�. ..�.�.......190 9 the cause of death being
0 Place of Burial..G (-64.. .
n.' Undertaker or 4t!'1A
: in charge of Burial,
erson
... f 9ned by)...
44144e-
hI Residence � 1� isL7 -a .. .. ....
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