STATE OF WISCONSIN

BURIAL PERMIT

Penalty for Burying Without a Permit, $20 - $200

Greenwood, Wis May 22, 1927

                                                                                  (City, Township or Village)

A satisfactory certificate of death having been furnished to me, as required by the laws of this State, permission is hereby given for the burial of  Betty Jean Tieman

Who died at  Farm, Town of Meade       in the county of  Clark

On May 22, 1927                      the cause of death being  Atelectaris (?) of lung

Place of burial:  Butler Cemetery, Town of Butler

                                                                 (Signed by)  R. L. Barnes

                                                                    (Registrar, Deputy or Sub-Registrar)

Undertaker or person in charge                                      (Sexton)

Dr. Cole

Date of internment: May 23, 1927                                   Butler Cemetery

                                                                                           (Name of Cemetery)

This permit must be delivered to the keeper of the cemetery where the burial occurs, and should be endorsed by him and returned to the local registrar of his district.