This permit must accompany remains to destination

Bureau of Vital Statistics                      Wisconsin State Board of Health

BURIAL --- TRANSIT PERMIT

Full Name of Deceased:  Chester Daines

Place of Death  Stanley Chippewa, Wis.

Date of Death Dec 20, 1968                 W                M           78

Cause of Death 

(Completion is not necessary for Wisconsin burial)

Burial, Cremation, Removal

Burial

Cemetery/Crematory

Butlerville

Location (City, town or country)    (State)

TWSP Butlerville, Clark, 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  R. W. Plansky

Date Dec 31, 1968              Address  Thorp, Clark

Cemetery or Crematory Authority Shall Fill Out Space Below

Body was  buried     on Dec 31, 1968  in  Butler Cemetery

Located at  Town of Butler           Signature  Arthur Morrison

(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.