De Marsh, Milfred a STATE OF VERMONT DEPARTMENT OF PUBLIC HEAL H
o Division of Vital Stati 'es
0 A Or�; ERMIf Burial Permit N 0
•A Full name of de ased. . ....
p Place of dea
( own or C'ty) ntp) ` State)
p Date of death s 19_._.... .'Color.... •
. .. Sex_... g _.Q__
(Yr.,w .. D .)
E Method of disposal__ _.. .... ..._._ ... .__ . ... _.__.._..._.. .... /. ,
cret ton, t sit, storage, Cet ter- r Cremator
y (Bari age, etc.)/ y y) _ -(Toy ) (State) u,l
a+ Funeral director ........_...._.._........ Address .. ... .... ... . 4- ..........._.... ...._ ._.,t...._._..___..._..1
--- — _ --==PERMIT- --- ----i __________ --
Q' A certificate of a h ing eened a quired by the laws of theState of Vermont, permission is hereby given to.... ..._..__..._......_
o
O to dispose f the body as above st ted.
(P'tu ral rector.or person f g.as s ch) ` `
Dated at..._...._.........._....... this '7vc2lif day of........
(Clerk' ., dress)
R Signature..
(Tow r Cit_ C erk)
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OU S ACE BELOW
tBody was or 2.._.e/ 19..,..Z. in... .:-,.J..'.�'-
(� (Crcm.tted ried, stored, .) A (Cemete or Crematory)
`� r
a�
Place /" e ..r..,. signature i
_ (Sexton or person in charge)
SEE OTHER SIDE
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