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The above to be filled out by Undertaker and attached to box containing corpse.

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The above to be filled out by Agent or Baggageman at the initial point showing description of ticket, exact route, and via what junction points the ticket reads.

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TRANSPORTATION OF CORPSES.

TRANSIT PERMIT.

No.....

In the....
.of......

County of....
(City or Township.)
State of

on the...
day of..

189.. Permission is hereby given to remove the remains of......

· aged...... years... months ......days, who died at..

(City, or Township and County.) ..day of.

..189.. The cause of death being..... which is a.

disease, and a Transit

(Contagious or Non-Contagious.) Permit being asked for burial at....

... in the State of Name of Undertaker.

Signed by

on the..

Name of Medical Attendant.

(Local Board of Health.)

(P. O. Address.)

State of ........

date....

.189.... I Hereby Certify, That the body of....

.. named in this transit permit has been prepared by me for transportation in accordance with the rules of the State Board of Health by being.. Signed

Undertaker. If Disease be Infectious or Contagious, Undertaker must make following Affidavit. State of....... County of ..

On this......... day of... ...... A. D. 189.. before me, a....

.in and for the County and State aforesaid, personally appeared....

to me known and made oath and says that all of the statements contained in the foregoing are true. Sworn and subscribed to before me this..

..day of A. D. 189...

[SEAL.]

Issued to.

No.
Name of Deceased

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(If a minor, give parents' name,)

189.... Age.

Years..

Months.

Interment at.
Date of Denth.
Place of Death.
Cause of Death.
Certified by...

M. D.

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Carrier

.R. R.

COUPON NO. 1.

R. R.

TO TRANSIT PERMIT. No.

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Ву

Taken at..

to General Baggage Agent. Baggageman of Terminal line and sent

2This Coupon will be detached by Train

(See Other Side.)2

Who died at

DIRECTIONS.
The person issuing this permit must
see that it and the stubs are numbered to
correspond before delivering.

This permit must accompany the body
to its destination and be delivered with it.

1

STATISTICS RELATING TO THE DEPENDENT AND

THE MONTH OF

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POORHOUSE, POPULATION IN THE STATE

STATE FOR DECEMBER, 1889.

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