Fuller, Cynthia Jane i ,
STATE OF NEW YORK. Form 5.
1
BUR1f% L FEoRMIT
i Name of Town, 2 [/s-' '/--o"z__
is (Village)and (ktunty.S _ ........................... ..............
.e {Dated),.. t......l... .... ..r`1'�
as
The Certificate of Death having been furnished to me,as reguired by the Laws of this State, permission is hereby .,
tgiven for the Burial of. G . s�pe, •�'..co .$
awho died at CrE" Town , in the County-of.. �'Y"'c '
on ��r 1 •(5; the cause of death being D "
8 Place of Burial,.... ...... ./............ .
tGL !�
o Undertaker or Per )4} / _. :fir. :..... (Signed by)....�J `�'`c f'l ?'
in charge of Burial,
i
8eeidence, �i•.. ...?Y. l�Y dial Title.)