Burial PermitSTATE OF MINNESA
DEPARTS ENT OF HEALTH Burial - Removal -Transit Permit
Section of Vital Statistics Registration Permit No.
NAYS OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
Lewis K. Anderson 2-24-1982 ❑ Ye ®N•
SEX AGEPLACE OF DEATH (City VIIUe. •r Ts- Wp) (C•ub)
Male 72 Excelsior, Mn. Carver Co.
METHOD OF DISPOSAL: I PLACE OF DISPOSITION (N•M d e .ftyy . ers•Yq) (CH7. VHI•t• •r T• --N0. Ce—ty. S( W)
® BURIAL ❑ CREMATION
REMOVAL ❑ OTHER (rpedlsl
Chanhassen Cemetery, Chanhassen, Mn
Carver Co.
SIGN= MORTJCIAVWR FUNERAL DIRECTOR BUSINESS ADDRESS
1520 Second Street, Excelsior, Mn. 55331
A erBHra4 N brll h•vlaF br HIN u re•drri by L-. ".W.. Y here►? WF 4 di.F •f this b"T.
SIGNATURE OF REGISTR¢R (City. VDI-• •r T. -.Up) (C•—ty) I DATE ISSUED
OF PERSON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OH CEMETERY OFFICIAL I
ABOVE OCCURRED ON;(D•N)