This permit must accompany remains to destination

Bureau of Vital Statistics                      Wisconsin State Board of Health

BURIAL --- TRANSIT PERMIT

Full Name of Deceased:  Emil Maslanka

Place of Death  1322 Broadway, Rockford,  Winnebago  Illinois

Date of Death  July 14, 1964

Cause of Death  Cirrhosis of Liver

(Completion is not necessary for Wisconsin burial)

Burial, Cremation, Removal

Burial

Cemetery/Crematory

Butlerville

Location (City, town or country)    (State)

Butlerville, 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.

Edward T. Reynolds; Permit signed by Arlo J. Anderson, Rockford, ILL.

To dispose of said deceased as above stated.

                                             Signature  Agnes V. Rubin, Registrar

Date                                      Address 

Cemetery or Crematory Authority Shall Fill Out Space Below

Body was  buried                     on   July 16, 1964 in  Butler Cemetery

Located at  Butlerville, Wis.            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.