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I i - STATE OF• NEW YORK,®
!BURIAL. Pal:RN/111 'r.
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(Village)il.a.tn andof Townoun t y. -411,"Or,,4r4t,0 a t.7.2.e64. Form 5 f
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(Dated,) eft-7
The Certificate of Death having been fu nished to me, as required by the Laws of this State,
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: rg_ permission is hereby given or the Burial of da, 2:1.6 . we'a:re-t-e-eof AgeAC-2-1
E (City erilailwyperuiri.p.)
L7who died at atZde , in the County of. elart/124.4L-
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on ...f 7; 19/t the cause of death bein 41140-a<
--t= Place of Burl lel £44.164.44,4t '6 te44.,2,Aez..,
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Undertaker or person ele46corette.14.
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._E in charge of Burial (Szg ned by).... ._. .C,'A
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i k , Residence 4:jZeZe-447k tos
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(Offici Title.)