Lackey, Ernest ----- --------- -----
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Form 18 -"AI 0
1PROVINCE OF ONTARIO
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The Vital Statistics Act i
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Iguriat Permit •
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Under The Vital Statistics Act, and the regulations, and subject to the limitations thereof, this permit is
-i granted to
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(Print name of funeral director,surname preceding) y
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1, (Post-office address)
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k for the purpose of the burial or other disposition of the body of
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': (Print name of deceased,surname preceding) r.
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/who died at._ . ... / ..... ... .. .... .�... s9%�?'Lf�� in Ontario
(Place of d
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on the dayof.. ... G%/ c/-119
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26a. Where the cause of death was disease,the division registrar shall insert that cause in the burial permit
from the Medical Certificate of Death in form 16. r
( nature o d,v 'ou91..r•egistrar)
el lion division) (Number) ;y
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� onth by name) (Day) (Year) ��
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