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OFFICE OF CITY CLERK No. 10292 ,,.4 NI
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BURIAL OR REMOVAL PERMIT is&
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The Certificate of death having been furnished me, as required by the laws of this State, permission
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is hereby given for the burial
who died att/ on "1.4.-4 f . 19_1/-
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cause of death bein Years I Months I Days I Hours- Age I
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Plaoe of burial.k. ‘.-Z)
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,T;ker or rson in chayge , 6...F1
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Penalty for Burying without a Permit, $3 to $100
OFFICE OF CITY CLERK
BURIAL(� OR REMOVAL PERMIT
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Name of Deceased
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Date of Burial
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Signature of Keeper of Cemetery