Van Dusen, Leonard b.
SWAIM OE NEW TOUR.
Form
BITRIAL PERMIT .
1(P Nit-el Town nty j„/. ! ...
•• illage) and Coufl • �•
(Dated,). . . .,� 19/e
The Certificate of Death having been furnished to me, as required by the Laws of this State,permission
a. is hereby given 4or the l$urial of.. C.. ..t 11.....�C •. .. ..�4g. •
(City or p.)1-3 e.
who died at • . ........ , in the County
�of.... ... .. ..
E on.. I C 19,0; the cause of death being. ... .P.:Ot-1- }' =4),A c. i?
Place of B ' l 2
Undertaker or��roro�rson l4.a .k earl-. (Signed by). ... .l•....1...
in charge of Burial,
hResidence.... ...... ' ••• .. (O4 .....a.)