STATE OF WISCONSIN

BURIAL PERMIT

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

Eau Claire - Nov 25, 1930

                                                                                  (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  Baby Tieman

Who died at  Eau Claire                      in the county of  Eau Claire

On Nov 24, 1930                      the cause of death being  pneumonia

Place of burial:  Butler, Wis.

                                                                 (Signed by)  L. H. Flynn

                                                                    (Registrar, Deputy or Sub-Registrar)

Undertaker or person in charge                                      (Sexton)

Chas. Tieman, father

Date of internment:  11 - 26, 1930

                                                                                           (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.