Lockhart, Janette •
4. Form 5.
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ST/O\E OF- NEW itt_m_{,..
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t I = BURIAL. PERMIT.
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, i Name of Town h
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(Village)and County
0 -o (Dated,) /.41 19/3
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The Certificate of Death having been furnished to me, as required #the Laws of this State,
I ro, permission is hereby g-iv z f r the BuidaLt( - S7C-4144.ii Age e F1
E (City or Townshi . --' ,i,
who died at h , in the County of
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b . on. etrot.t./ / 7 19/.3; the cause of death being c.,11 /Ofe-f-.4.-p(--a4-e.57
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Undertaker or person
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I Residence C2 - e-c--t.--, 73 a-16
' -- J 44 (Official Title.)
q.
BURIAL PERMIT.
Name of Deceased,
Date of Death,
Cause of Death,
In the Town (Village) City of
County of
NOTE.—This permit is only to be issued for a
burial within the county 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 of a death certificate.
NOTE.—Burial Permits,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.