Stevenson, Maryann Form 5.
BURIAL. PERMIT.
co
y
' Name of Town L
1(Village)and County.) j
a
-o
a (Dated,) �/�!d'1 z9/ -, '
I The Certificate of Death having been fu nished to me, as required by the Laws of this State, i�,
a, permission is hereby given for the Burial of_. Aae
E or Township.)
0
who died at o , in the County of._)1 Alt- '� 11
on 7 .Q�/ki z9/2,, the cause of death being 173 kir.C42 ?-
e Place of Burial
y Undertaker or ersoli
in charge urial, �� � � / (Signed by)
g of c -1
��ii Residence_.-.. .. J (Official Title.) 11