Wood, Lyman DIVISION OF VITAL STATISTICS BURIAL-TRANSIT PERMIT ,,,,
Form VS-14 (R 12/61) PERMIT NO.__ 7''
NAME OF DECEASED
DATE OF DEA"'
PERSONAL `--
DATA ON S:PX AGE P OF DEATH1 (VILLAGE` OR CI CO'IINTY '.7 ,
DECEASED
CAUSE OF DEATH ./
MANNER AND -B-URIAL ❑ CREMATION ❑ OTHER
PLACE OF SPECIFY
DISPOSAL NAME OF CEME / /iCOUt+1 irt,,t ' ' ee.a�
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A SATISFACTORY CERTIFICATE OF DEATH OR PROVISIONAL CERTIFICATE OF DEATH N FILED AS REQUIRED BY THES
OF THIS STATE, PERMISSION TO DISPOSE OF THE BODY AS INDICATED ABOVE, IS " TO' ✓✓✓///
AUTHOR- 7-1 /
DISPOSE OF TION TO
FUNERAL % �, /i �, 7 Alk /�� l
DIRECTOR'__ G ADDRESS ' ': f
BODY S REGISTRAR i, REGIST : IRICT NO. DATE OF ISSUE
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This permit must be retained by superintendent or person in charge of etery for a period of(5) five years
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