Transportation of Corpse Form__,- _v_ a s,M
FOR USE ONLY BY MINNESOTA LICENSED EMBALMERS
MINNESOTA STATE BOARD OF HEALTH
TRANSPORTATION OF CORPSE
Name of Deceased-,(-'
I
Place of Death _._.... ...
Date of
Cause of
Contributory Cause of
Age: Years
Occupation _74
Place of Birth— L
frame of Father_.
,Maiden Name of Moil
(Original) TRANSIT PERMIT NO.
PHYSICIAN'S OR CORONER'S CERTIFJCATE
✓ y(c s-.
Date_----- :__.....__:.. -----'--�-----.... _- 19--
:.....___
__._....._....__.._........._.Duration_— ... ....... .... Days.
_._-...___-____..... ..... Duration_ .....__ ._._.._... Days.
---.,.-3 ------------- _.._..
Single, Oke
(State or Country.)
.--Birthplace of Father -.1,J...
r�t��-
..._.-Birthplace of Mother
-._.4_1
SPECIAL INVORMATION.
or
(Onip for fiospitab, in t r .. ae^v) 3 t 1 Awl.
Former or Usual Residence.. ... -_.
How long at Place of Deaths..___-.7--jr¢
Where was the Disease Contracted if not at Place of Deaths
I .hereby certify that the above is true to the best of nyArnowled rad b
..:,I. D.6,r-En
eyQer
Residence ___....._ - __.._._. ____.__.County of _:.._:. _.._...State of...__ ..._�J`,*;*; j.
PERMIT OF LOCAL BOARD OF HEALTH
This Perruit must be properly signed, and with Phyaielan•s CerNBcatepresented to the Railroad or Express Agent be are b y ran be shipped.
L- the
County of -
__.._
State of
Permissions hereby given ,to t
in the Coug/j�y of --,Q. ��
the body6Y��1��-�G.2
who died at—
day of._........6.. �S?�tri.(�L/f,
The cause / eath being_.__
To be accompanied by -__Z,
[If Ch, or Toss, afx
Corporate Seal.]
on
e for burial at
State or����..___.on
which is
19oZ$J
._____...._......._.as escort.
_.._... ____�.__�/�.. _Health Officer.