Hall, Dufaut • ..
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II 1 N
• STh T E OF NE V� �S �� R o Form 5.
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BURIAL. PERMIT".
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. . te I.,.4',. :2.../ei
• f Name of Town t /�"!)
•• o ((Village)and C ty.J
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l/l�C.v�i (Dated,) 6V--Ci1. ' zq/Y
The Certificate of Death having been furnished to me, as required by the Laws of this State,
permission is hereby g er for the Bur of 44fAge
'E (City or Township
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• U
• who died at , in the County of
e
1'• = on zg�7jtlze cause of death being
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• Place of Burial M
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Undertaker or person
. . .... (Signe r
in charge, of Burz l ��� �� ���� �f�
• 71 V, 1
Residence
, J (Official, Title.)
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