Van Husen, Jessie ' ti� Dist. No?-1 2-9___ STATE OF' NEW YORI( Registered No.
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aY� BURIAL PERMIT
�'E^ Town (Village) cf Fort Edward, Washington County, __.2. -. 19____
T_F The Certificate of Death, having been furnished to me, as required by the Laws of this
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Z - u State, permission is Lereby given for the Burial of __ Q• _-Q w -(. ,
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a Q; S Sex Age__ __,3 who died a(tr Fort Edward, in the County of Washington,
ca on 19_ y; the cause of death being__ ___ _
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.4',4 rie.ww.t1 or 511 a...A.4r LA*".'
Place of Burial-_ vV- `'t4 = ti �- c
a=� R Undertaker or person l
Z. P4 3, t __ v _b �G�^
w Nx;;b Pa in charge cf Burial, 1 s _ ;:
"°�- E" ,r sa �.ao avC Town Clerk or egistrar of V. S.
p m o J Residence-
BURIAL PERMIT
Name of Deceased
Person in Charge of Burial Ground or
Crematory must fill out this part, and file the
same with the Registrar of the District in which
the Cemetery is situated, with_'n seven days
after the disposition of the body.
Date off Interment
Cremation 19
Signed
Filed -19
Registrar of the Town and Village of Fort Edward,N.Y.