Burial PermitSTATE OF ESA
DEPARTM NT OF HEALTH Burial - Removal - Transit Permit
Section of Vital Statistics
Xo-�3.3L,
Permit No
NAME OF DECRASED
DATE OF DEATH
DEATH COMMUNICABLE?
Amanda
Koch
Aug. 9,1958
Yea ® No
[:]T_
SEE
COLOR OR RACE
AGE
PLACE OF DEATH (City Villa„ or Township)
(Couty)
remaill
white
79
Doctors Memorial Minneapolis,
Hennepin
METHOD OF DISPOSAL:
PLACE OF DISPOSITION (Nome of eemetey s
or ereatory) (City. Village or Township. Comity. State)
BURIAL 1 1 CREMATION
Chanhassen Ceme Chanhassen-
Twp Hennepin Minns
❑ REMOVAL El OTHER Opeeify)
SIGNATURE OF MORTICIAN OR FUMEVAL
DIRECT919
BUSINESS ADDRESS
6
I Huber Funeral Home
E=elsior,Minn
io A a of death basin, been filed u repaired by Is.. perreiseion ie hereby ,iron to dispose of 2W body.
sARA.TI*E A Rw*rRAH A-,*, s --v of"CDMWHInao or Township) (Comb) J DATE ISSUED
SIGNATURE OF PERSON IN CHARGE OF
STATED I SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
9-10.67 1500 Bk.. Ree. No. 42