Therien, Joseph Always write with ink.
CONNECTICUT STATE DEPARTMENT OF HEALTH
TRANSIT PERMIT No._Y
PERMIT OF LOCAL REGISTRAR
To remove a dead body for burial beyond the limits of the town in which death occurred,a transit permit
must be o'infd 'om the local Registrar I
Name of Deceased ` /// ' Date of Death /" F/ Y /
Age, a ye � m s "' days. Sex_.CifP Race or Color
Cause df Death(1) (2)
Attending Physi ian- ` ddress U / -
Place of D Embalm —_--No.y 7‘_
Underta er 9- dress_- —
The body has been prepared for removal and shipment in accordance with Rule of the Rules and Regulations of 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, /�
FROM_ • T13,4_ = _! ,t
Via Date of S • m ! _— ._
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Date 2, ' /�rJ Registrar of is zat _ —
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