This permit must accompany remains to destination

Bureau of Vital Statistics               Wisconsin State Board of Health and Social Services

BURIAL --- TRANSIT PERMIT

Full Name of Deceased:  Grace Mason

Place of Death  Twn of Butler, own home, Clark Co., Wis

Date of Death  Thur 6-10-1976               White       F         64

Cause of Death  Heart attack

(Completion is not necessary for Wisconsin burial)

Burial, Cremation, Removal

Burial

Cemetery/Crematory

Butler

Location (City, town or country)    (State)

R #3 Thorp, Twn Butler, Wis

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.

Don Izydorek, Thorp, Wis.

To dispose of said deceased as above stated.

                                             Signature  Russell Mead

Date  6-14-1976                  Address  Thorp, Wis.

Cemetery or Crematory Authority Shall Fill Out Space Below

Body was  Buried     on June 12, 1976    in  Butler Cemetery

Located at  Town of Thorp            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.