STATE OF WISCONSIN

BURIAL PERMIT

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

Township of Butler 1918

                                                                                  (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  Duane Edmond Shoemaker

Who died at  Township of Butler        in the county of  Clark

On Oct 10, 1918                       the cause of death being  cold and influenza

Place of burial:  Butler Cemetery

                                                                 (Signed by)  Arthur J. Feild

                                                                    (Registrar, Deputy or Sub-Registrar)

                                                                               Simon Arnold

Undertaker or person in charge                                      (Sexton)

B. A. Cole, M. D.

Date of internment: Oct 12, 1918

                                                                                           (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.