Van Hussin, Fran I
i
• Form 5. '
Z TATE OF s� EW PORK®
t
BURIAL PERMIT .
Ca
o Name of Town a(/tl
• ° l(Village) and County.
' (Dated,)..,► ` f 19if
•
• ,,
The Certificate of Death having been furnished to me, as required by the Laws of this State,permission j
• �/'
is herebygiven or the Burial o .lt. K iserG.,,�
e o ( ityor nship.) f !t*.4Ln...t.at.cCiJ�,Gr,. Age �G.
who died at.... , in the County of
i ti 2
E on 19113; the cause of death being. .. . . .z.. .:/& t,: s ;, Y9,.r
e Place of Burial... ..
a Undertaker or person f d�
' • (Signed by)
s in charge of Burial, ••
h
Residence..
9 -7'4T-i5-4-4......,— (Official title.)
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