This permit must accompany remains to destination

Department of Health and Social Services

Vital Records                                 PERMIT FOR DISPOSITION OF DEAD HUMAN

                                                                                   (Burial - Transit Permit)

Full Name of Deceased:  Clarence E. Butler    Male     White

Place of Death  St. Joseph’s Hospital, Marshfield

Date of Death  June 18, 1981

Cause of Death 

(Completion is not necessary for Wisconsin burial)

Burial, Cremation, Removal

Burial

Cemetery/Crematory

Butlerville

Location (City, town or country)    (State)

R #3 Thorp, WIS 54771

A certificate of death having been filed as required by the laws of this state, permission is hereby given to Funeral Director or person acting as such.

Donald R. Izydorek, Thorp F. H., 110 West School St., Thorp, Wis 54771

To dispose of said deceased as above stated.

                                             Signature 

Date                                      Address 

Cemetery or Crematory Authority Shall Fill Out Space Below

Body was  buried   on  June 22, 1981                       in 

Located at                                     Signature  Arthur Morrison, Sexton

(Sexton or Person in Charge)

This permit must be endorsed by the sexton (or by the Funeral Director where is no sexton) and permanently retained in the Sexton’s files.