Morse, John I -
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•• 1 — Form 5
STATE- OF PI-E\°A!r yoRK.
ti.iriaLutr/a
1. = I E3URIAL- F) aFR NA I T.
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61 of .40E,
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i(V i 1111aagrne j and dTvn County.
• "C3 (Dated) 417.4-.4 1 7
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The Certificate of Death having been nished to 1 e, as required by the Laws of this State, 1
.. 1 -i i permission is hereby given for th.:- Burial of 0`fict, - Z(.100-7./. ... Age740-if' '1 1
* E 1 (City er—T-erAR4444.) tierre4".3 .7 •who died at
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= r , in the County of aret/717/cA-1- il
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on. / -,1 li. 19 It the cause of death being. 17-0-144./t., Ca, /I: .
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Place of Burial. di artft/
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'1 iun n dcheartragke erof rB puerrisaon /,r
(Signed ,
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• !, ,-, •.11444/3 t.7a. / 1 6)&7vg
• I, , ! Aesidence , J (official Title.)