Buckbee, David 1 n Form 5.
STATE OF NEW YOUR*
-r. BURIAL PERMIT .
. m
i N
o { Name of Town t
7(Pillage) and County.f "' ayfr-
>,
(Dated). .I E. 19f3
The Certificate of Death having been furnished to me, as required by e Law of this State,permission
is hereby g t o r o vven for the Burial of ��: mi
'4C�f ...... r�S„�GRr Age..Q aA
(
who die at , in the County o
E on. V V
I913the cause of death being.
.�� �G�l �. . . .. .. . �.�1+.:... .
etral
P ce of Buria
• yr
°" Undertaker or persona 14frit� k • (Signed by)...di
s in charge of Burial, '" " '
hResidence...--5-"-.1-1.--;/1— G��� ,� (Official title.)