Chapman, Alice f -Form5
STATE o NEW TISKK® .-.� 5,,
BURI PER T. `` n
i m
�� ( a''Z 'I,-- -i( N�ameaof Town 1_�_ / //i o !
�, nd County.r ' /�
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(Dated)S / b I9/`.
The Certificate of Death having been f ni to me, aLre ired the Laws of this State, ,
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_--g - --per�-,niss oia zs e-eby a i ro7' the Burt*-I of
e.--�-1�a 1s e-
a �
E I (City or Township.
who died at - __ , • he County of
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",
on._- �/{ 19/3the se of death being G� ,' "
44;4-
E
Place of Burial
' 1 Undertaker or person /1
in charge of urial, • ig—*14Szgned by)----
i
Residence- -- - ---------------- ---- --- - -- (Official Title.)
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BURIAL PERMIT.
Name of Deceased,
A(7
Date of D atla,
72fr /3
Cause of Dekth,
rai*I'AL S61i 'c44'24. )*.V Ziktt
In the Town(Wiliagepiiiity of...
County of ..
•
NOTE.—This permit is only to be issued for a
burial within the coun =where the death takes
place,and is to be kept by the cemetery keeper
where the body is buried. It is to be issued on
the filing cf a death c'rtificate.
NOTE.—Burial Perm.ts,and all Blanks are to
be procured of Town and Village Clerks and
Boards of Health, for the Registry of Births,
Marriages, Deaths and Burials.