Durfee, Ralph (3) Pe 't for Burial, Entombment or Removal.
Issued to __ _ _ C No.
County of STATE OF VERMONT.
p Town or City of________ c
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6 Date Jof Death ..r r 193 7
FFull Name l4 + `-' Agee— 2
�"'� YEARS MONTHS DAYS
Place of Death __Ai )4-x V
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z w Disease causing death — _ n tt 1
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wz Medical attendant_-.--.__YV ` __ 1) - --
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5 i Proposed date of'burial, entombment_or removal___ V ._A.-4 / �1 193 7
c Proposed place of burial, entombment or removal____ _ 3 -„ 1 __ f. . p
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ZWhat cemetery or tomb
4 Manner of burial, entombment or removal ___c/4.44-g a-A-4-4, _
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A Undertaker___ cez-�—
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Address '•-. i
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to
w A Certificate of death (or removal or transit pe it) having been filed in my office in accordance with
Z law, I hereby authorize the!' 0ak. e,.a.4.41 _of the body of said deceased person as stated above.
(BURIAL, ENTOMBMENT OR REMOVAL)
4 ,----Lif—c.-ce--t.-.4--°1--r
Town o Clerk.
Date_ C / O — —_19,8 7
This Permit, i operly made and signed, is authority for the burial or entombment in any cemetery or tomb in this State.
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c� 0 3 Werebg Qertifg, That I did, on the__LO_day of__ ____19'g,
deliver the body described in this permit to _
�� Sexton or Keeper of�_ ____ __—_ _.._ Cemetery for
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3 a Signed —.—
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4, M � (State title hen.)
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Tx' o.g Vt., --19
ab-' .31 erehg (tcrtifg, That I did, on the___. day of
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°p m (State what disposition was made of the body.)
to
H d� the body described in this permit.
°� x� o2 Signed ���(.ld L.
y,M (Sexton.or Keeper.)
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