Hodgman, Charles w
V
Always yr ite with ink.
TRANS' I 14 .RMIT No.
CONNECTICUT STAT , 1 m -MENT OF HEALTH
_ -- PERMIT OF LOCAL REGISTRAR
- e remote a dead body for burial beyond the limits of the town in which death occurred,a transit permit
must be obtained from the local' i
�-��t,tt , 9 l a
Name of L)eceast.id- -,` G
��(,'t Date of Deathj� «'� — 7 F
Age, .5`9 years '/ months "7 days. Sex h'""[ Race or Color " a •
Cause of Death(1) (LI U t /4-t U...N'y (2)
Attending Physician W, ( 4t 4wt Address_ °"''-'t"^
%
Place of Death M.�Alt t�_a eC 1f j mod) ni C Embalmer 2-� C9' 3 at No.3'1 V
Undertaker 'v`As''-t r(* el ty,, 'l/
Address ' ` -4., t #
The body has been prepared for removal and shipment in accordance with Rule of the Rules and Regulations the STATE
DEPARTMENT OF HEALTH.
The Certificate of Death and the undertaker's statement that all proper measures have been taken to render the body harmless
for shipping,having been filed and recorded, PERMISSION IS HEREBY GRANTED FOR REMOVAL OF THE ABOVE NAMED
BODY,
FROMlt ' '
Via ' _ c 4-ti.-4/1-9 Date of Shipment 41;^ ,�# 0 /�,(P
Escort_ __ —__- 0 tG V+� 9 /
Dat _ Qi& ) Gft, a, , Registrar of h ta...,a n e/"
r orm S-9 10-25-1OM 1' /
a D "' _ L P_ . -
�
orots-
�nes, x e �„ '"' •„ '- �s� - ..:`" �� �` =' ter` r �� �' '.�C+ - - - -
• t a+a xis<`
•
.7 ate m ;=�`
- t ,� -? =cam- - -
.-��y:�`' - - 'w^
+
-rt cam.,. ? �.�" _ -�, -- ,'y -i, ..r _- M1
�� ..c
'i -"' "+.
x .r:�-a .,y� -•.��as '=''. _ -s«�* -ter `:
"._. > .3. ' ,:.'` ,+ ;'§ _ -vim •.."`.'' .-ram`'- •
- ._