Van Dusen, Ira Form 5%
4 f STATE OF NEW YORE.
BURIAL PERM IT.
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1..) b 2„ _2 The Certificate of Death having teen f rnished to me, as r quired by the Laws of this Slate,
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No t: ei':.'•' permission is hereby given for the Burial of a- a.
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73 "O.22.. E cic.,,c_ayire Township)./3
Sex )14-Lec Age gr"d who died at , in the
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County of_111 ______________ on 0017/2--- 19/ 4.the cause/
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0 • 9,-.5"a :'.E of death being Place of Burial4-.71--"-41--c-2-6-6 • GP-4=e-4.----
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Undertaker or person t iii( /fl a.....z , (Signed by)
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E in charge of Burial, f -
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' •,`' i Residence • (OVER)
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