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The above to be filled out by Undertaker and attached to box containing corpse.
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.
TRANSPORTATION OF CORPSES.
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.
Name of Medical Attendant.
(Local Board of Health.)
(P. O. Address.)
State of ........
.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...
(If a minor, give parents' name,)
COUPON NO. 1.
TO TRANSIT PERMIT. No.
to General Baggage Agent. Baggageman of Terminal line and sent
2This Coupon will be detached by Train
(See Other Side.)2
Who died at
This permit must accompany the body