BURIAL PERMIT

Issued in Compliance wth Chap. 202, Laws of Wisconsin, 1897

April 3, 1931 Town Mead

                                                                                  (City, Township or Village)

Archie Worthington

(Here give the name of person to whom this permit is issued.)

You are hereby permitted to remove the remains of

Name of Deceased:  Robert Worthington

Date of Death:  April 3, 1931

Name and location of cemetery:  Butler

Name of attending physician or other person signing death certificate

Dr. Boeckman

                                                        W. A. Schlinsog

                                                         Town Clerk