Kirkpatrick, David 5 Dist. No. STATE OF' NEW YOHIC Registered No.
do 'e
a�V. 0 BURIAL PERMIT
02
C. r o te--- 191Y_
�I • ' A Town (Village) of Fort Edward, Washington County, -----
‹t N 41 o
x/ � \� F^ � The Certificate of Death,having been furnished/ to) me, as required
/by the �Laws�of this
iv^y Ds
Z x v�,� � State,permission is hereby given for the Burial of
'" ' y w a y�,� G
v ° v a L`r ____Age
who died at Fort Edward, in the County of Washington,
Z g,vy Pi Sex-- --
In -3 ti° U --. 19lr_-;the cause of death being- /
w ) 4°'PS Place of Burial ---
Q i�l a"- Undertaker or person Ems/
Z C4 °a2•3 '" •
d
w ' °°'�-C ^ in charge of Burial,
o 'd `GR�m i1>L
/�/f n
d �rw or�lVJ/ Town Clerk or Registrar of V. S.
A � I�
l i E+�o^ 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 of}Interment
Cremation 19
Signed
Filed 19
Registrar of the Town and Village of Fort Edward,N.Y.
Pirt:4.44 — a-t-', 7/i cf.