STATE OF WISCONSIN

BURIAL PERMIT

Penalty for Burying Without a Permit, $20 - $200

Thorp, Wis Dec 5, 1930

                                                                                  (City, Township or Village)

A satisfactory certificate of death having been furnished to me, as required by the laws of this State, permission is hereby given for the burial of  John Jay Elmendorff

Who died at  Thorp, Wis                       in the county of  Clark

On Dec 3, 1930                                the cause of death being  convulsions following

Pheuro - pneumonia

Place of burial:  Butler Cemetery

                                                                 (Signed by)  Myrtle R. Smith

                                                                    (Registrar, Deputy or Sub-Registrar)

Undertaker or person in charge                                      (Sexton)

H. C. Conklin

Date of internment: Dec 5, 1930                                    Butler Cemetery

                                                                                           (Name of Cemetery)

This permit must be delivered to the keeper of the cemetery where the burial occurs, and should be endorsed by him and returned to the local registrar of his district.