Thomson, Charles •
•
•
•• I ] Form S.
STATE OF NEW ORK.
: _..: /,(7-Th •
. .cd
•
E3UIIA F=2' H FR NA rr„,
• on - .
s o
•
• =
•
c'• -.-- 1(V i Lagme j andTro un /- . 7. "----- ----..-'-'----"-''
• d
a •-•
• o (Dated,). .
The Certificate of Death having been furnish to me as re uir by the Laws of this State,
=
• permission is hereby giv•;for the Burial of , Age
. E = (City or Townshie-4..... c.... „.._...ZZr“_.__,"
•
• E who died at.,_ -rair t"-- : , in the County of
. ,,'
. - • /
6 .
t = on „,V7/177/- 7 19,2,the cause of death bein
s E
t Aidoor
Place of Burial .C/ / 41-611,v1.4-07-,.. /
. .
Undertaker or person ictc_Zyzia/2AZy.
,00"-Signe, by , .,./. ...
---
. :z in charge of Bz -' l, -
O F—• ,,' / /
« Residence 7c.c-/-4----- J (Official Title.)