Dubee, Helen Always write with black ink.
CONNECTICUT STATE DEPARTMENT OF HEALTH
Hartford, Connecticut, U. S. A.
REMOVAL, TRANSIT AND BURIAL PERMIT
(This permit is sufficient for removal of a body to any town and also for interment)
No.of permit ���� J q 1
4 Date 'OW171 64'S` / ! .5-
The certificates required by the state statutes have been received and recorded, that the body has been prepared in accordance with the Public Health Code.
Permission is granted to remove the dy of
2i �� If eteran
/ name war
who died at ..���� //y� 470 on '// / / !6 �►
Date of Birth Age(in years If under 1 year If under 1 dayay
last birthday)
f� / Months Days Hours Mins. }. t`
/j �/( e9'� 7� Sex / ". Race or Color ___ �'.. A
Cause of death _ / —Z'<'-‘4
for Burial in . ",17 ' ��� Cemetery in .LW—
(Name of Cemetery) (Town) (State)
�� Fun. Dir. C —" l
Issued to �G���2 GfiYl��L �i�� /'X.� or Address Saa,
Embalmer . 1.6v9:),____:
�j
Embalmer's License No. //.3777
Registrar of Vital Statistics
THIS IS NOT A CREMATION PERMIT
Town of HARTFORD.
Form V. S. 9
NOTICE
1. No body may be buried without a permit from the registrar of the town in
which the person died.
2. The permit accompanies the body. If transportation is by common carrier,
a transit paster (VS 10) must also be attached to the box.
3. This burial permit must be given to the person in charge of the cemetery.
The sexton of the cemetery is required to endorse this permit with the date and place
of interment and forward it to the registrar of the town in which_ the cemetery is
located.
4. A temporary permit (VS 26) is good for only 24 hours.
5. If the body is to be cremated, a cremation permit (VS 48) must be obtained
in addition to this permit.
SEXTON'S ENDORSEMENT
The body for which this permit was issued was buried
in Cemetery on .1-10--a-C/ -e--A/....0.. 19 --4/
14. 1 xton
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