Burial PermitForm H 4T.-
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Department of Public WelfarewwwDieviesiolliof Publise Health
Office of the Local Registrar of Vital Statistics =
MINNEAPOLIS, MINNESOTA _=
ROOM 3y
-
City
A certificate as required bp late having- been filed, permission is hereby granted
for the groper disposit' n o the !.�matns of.•f-
Name........... . .......... -- -------- - `--------------- ------------------------------------------------ Se ................ -----------------
'jam MARRIED -
�% '�
Date of death a vt _
--- ------------------------.- - L=-- '==`- --.--------------- octal State =
95
-- - - DI:
- Cause of death.-------------- --- ------ •---- - --------------------.........._.........._..._.._....__..........................
H Medical Attends -
Place o death ...... --- ---------- ......_......_........................._..........._.......................... :.......... -- .------.-----._. -
.f .-- .. ..--- ..... -
-9
N
Place of dispositto .... .. .... .......... ....._..:........ .Date..........._. Z...........
SS
Undertaker .................... ...... ............... .......................................... A ddress ......... ! ...:: ... -----. .---�----. _
Permit =�
No.
......................................
...--.....................•-..............................
Commissioner of Health and o a/ kegistrar. —
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