Haviland, Ford Form D
STATE OF MAINE BURIAL PERMIT
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Permission is hereby given
to rove and bug the remains of /AV; utill.
$Y-A--'t--d-,
inZeilt,e, ' Cemetery, Town 7
,
Date of Death 9--- r/06:4 Age)7:- years C/1 months 7 days '
Place of Death.
Cause of Death... - • 1111 '--u---ta-1-,--/-- --t)
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Medical Attendant • 4 i . 2t Iri:
No
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,., City or Town Clerk
(Over)
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Signature of person having charge of cemetery
This Permit must be returned to the Clerk of the town or
city in which the burial takes place, within SIX DAYS after
burial.
Any person acting as Undertaker without a Burial Permit
will be subject to a fine not exceeding one hundred dollars,—
Chap. 1, Public Laws of 1933.