Chadwick, Volusy --
� � Form 8
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STATE OF NEW PORK.
P
. BURIAL PEFRMI 'T'.
Name of Town 1 L (CC1Zr_ 2 v
,�. 1 _(Village)and County.c
(Datea�)�( cif 191
4
;= The Certificate of Death having been furnished to me, as required by the Laws of this State,
a permission is hereby given for the Burial of�� / ✓ " Age 1-7 I
E ; (City ewwslhip.) �
• . 1 who died at ✓,� � in the County of Xl�4ir�t.s
* e ,
• ....
on o 19//, the cause of death bezngeictrvta
ecstc
•
Place of Burial Zia eici4, o±r-,� (L3 ��,„,��: icrf
Q
• Undertaker or person
Si ned b
+ E
aid
• 1 .- in charge of Burial, } g y)
s �Ec � ,s Residence (Official Title.)
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