Potter, Raymond t
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S ATE OP NEW Tc)RK® Form 5.
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.� BTTRIAL PERMIT .
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L R. Name T Y�j'
(Pillage)of and own County. +B
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(Dated). 1.90132
cThe Certificate of Death having been furnished to me, as required by the Laws of this State,permission
a. is hereby given for the Burial of.. ... ... e®h,(.G �!1L. ��m Age...l) `,di
c (City or T ship.)
who died at . . .. in the County of... r, /., ta,
Eco .4-G el 1J of g•-�rYldq-44.•-Ll��-.t+ ..d�/.4.,4.
ion he cause death bein
.. /`�j GL�c
i I Place of Burial...Ott-t— 7 4 17 "`�
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Undertaker orperson G ..
h in charge of Burial, —'�"' ' ' • (Signed by) �1 :.�,.�. .l c ��
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Resident•�... (Official title.)
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