Burial PermitBurial -Removal -Transit Permit
Permit
NAME 9F DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Estella Johanna
Andert
5-19-1998
E] YES ONO
AGE
PLACE OF DEATH CITY, VILLAGE OR TOWNSHIP (Cd/NTT)
Female 92
Apple Valley, MN. Dakota Co.
OD OF DIS OGAL:
PLACE OF DISPOSITON INANE OF CIMETERY OR CRUMATORYI ICITY,VIWGE OR TOWNSHIP, CWMY,STIR!
aBURIAL ❑ CREMATION
OREMOVAL❑ OTHER(SPECIFY)
Pioneer Cemetery, Chanhassen, MN. Carver Co.
SIGNA R IAN Oft
BUSINESS ADDRESS
a--1
520 Second Street, Excelsior, MN. 55331
A certificate of dea h havin
been filed as required by law, permission is hereby given to dispose of this body.
A R R GISTRARCITY,
VII"GE OR TOWNSHIP) COUNTY TTL!
DA ISBUED
'or, MN. Hennepin Co. Sub Registrar
5-21-98
A REO ERSON IN CH GE OF CONVEYANCE
AU7HORIZED DISPOSITION
SIGN RE OF S OR CEMETERY OFFICIAL
DA/TE RECE(/I VED
A STATED ABO pp
6�
OCCURRED ON:y(DATE) 7�� /
/
I6p
HE-00113-03 (7/84)
This form provided by the Minnesota Department of Health, S ion of Al Statistics Original—Place of Disposition Copy—Sub Registrar