Foley, John STATE OF NEW YORK. Form 5.
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BURIAL PEFQI\'IIT.
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The Certificate of Death having been furnished to siffas required by the Laws of this State,permission is
g hereby given for the Burial of . '-- -" -°'" Age,_---
o (City or Township,) b^" -
O who dud at _ r '�'
y t,-in the County of =
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Iz � • the cause of death beta -=
Fil
4. Place of Burial T y `--
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p, Undertaker or person ''` "�- '�
b in cha^-fie of Burzal r (Signed by)
41
Residence
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