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STATE OF FI:ORIDA )
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COUNTY OF ST. LUCIE )
Before me the undersigned authority personally appeared
S~MUEL GAINES, well known to me, who first being duly sworn
and cautioned, di3 d?epose and sa~ as follows:
1. That he is the owner of Stone Bros. Funeral
Home, 317 N. 7th Street, Fort Pierce, Florida.
2. That in the records of the above-name8 Yuneral
home is an Burial Permit issued by the County Health Depart-
ment of Riverhead, Suffolk County, New York, ahowi~$ that one
03CkR GILBERT died in that county on November 3~,1955•
3. That the above-named Burial Permit, a coP9 of
which is attached hereto, is a legal document granting per-
mission for the burial of the deceased named there~.
4. That the above-named OSC~& GILBERT was subse-
quentl~ buried by Stone B~os. Funeral Home on November 13, ~955,
in St. Lucie County, Florida.
Further Affiant s~yeth not.
,
Sworn to and subscribed before me this lOth d~ of Octobe~?~~~~~~?p.
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My Commission expires: 'd~
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June 30, 19?1
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