Sprague, Alvin j
Permit for Burial, Entombment or Removal.
xIssued to 0t,9, .1- o. 2. P\
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County ofnstn�ci- STATE OF .
Town or City of 9..1h,,rsgfAtkat. fl. L f .
Date of Death `.1 Yl ai_.rt 13 190-0
E: Full Name QL,,,x-"". % Age E 3 a 3
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�(1 ^.� ;; ,_ YEARS MONTHS DAYS
a R Place of death L ssy �,��in�!_� u;,ti; F `•
41 • Disease causing death -�A".,tti. P.�e"�irua..
04
wz Medical attendant 13.st-. 01. 1 Cp1.041.11c.4rtf,.►_
j--Proposed date of burial,
za Proposed place of burial, _ ,_ $ try.' e�" A,
6 What cemetery or tomb C�.n1 C1.012A-
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.Manner of burial, tombs�t a vai
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q Undertaker R 1 4 t". ....4.44.4.)-1-4
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w Address C\.Qs •Q,. —VI q A Certificate of Death(or removal or transit permit)having been filed in my office in accordance with
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5 law, I hereby authorize th of the body of said deceased person as stated above.
t URIAL, ENTOMBMENT OR REMOVAL]
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- W S
OWN Oil I CLERK
Date `W..n I 19
This Permit, if properly made and signed, is authority for the burial or entombment in any cemetery or tomb in this State.
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3 4rrrbg Qtrrtifg, That I did, on the _ Y of . 19
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deliver the body des i ed 'n 's p rmit t
A d Sexton or Keeper of //l etery for
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0 4.0 Signe
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°4-1 q m (State what disposition was e of the body.)
H ,to the body described in this permit. e
Z�, Q 0 /4.4.riacA71i of P0; Signed A' `
w + a°i w° (Sezton,or Keeper)