Burial PermitX't- 'f.'/
PLACE DEATH STATE OF MINNESOTA
County. REGISTRAR'S
REGISTRAR'S
Township �.�ti�'.i �l+t�y--� No..._ ............. _..
OR
Village...
OR
OR Permit for Burial or Removal
City......... _....____......._.. _......_.. _.
Date of Death ........... OC ? ...(q ....... .......... 19/4�1-
Full Name........... C�c..f::7i.� ........
'rn Age......... r -....... yrs.
Sea..... Gi._.............. ...:Plat of Birth....... :z- .....................
9l I
Disease causing death.....ar,j*L_%......
Medical ��� . -�yc� Proposed date of
attendant}.......:.... w`'y...burial or removal}19fi
Place of burial.....cl,r/Jf�� ro..............................................
Placeof removAl...........................................via.................................
Undertaker.... ..............Address... .. .
A certificate of death having been filed �'y my office in a� once with t e laws of
Minnesota, I hereby authorize the ............... �,.Y.............................. ..................6 the body
(Burial or Removal*)
. a .
of said deceased person as stated abov case of death from a dangerous communicable
disease, the burial orb e c nducted a etding to the rules of the State and
local board of health."`
.._...___.. ..._Y.-:. ......._�
....._ ... regretrarof Deaths) '••
Dated... ...:.. .:....:_ 19............................................_.......................
Official Title
Write "Burial" or "Removal" as the case may be. Burial permits most be delivered by the Under-
taker to the Seaton. Removal permits must be given to thaAgent of Transportation Company, and attached
by him, to boz containing body. Subregictrata will write 'sub" before the words "Registrar of Deaths"
and "Lmensed Embalmer N.. .............._....... below, always r v g No. of License. Fine or imprisonment
for receiving a body for burial without a permit._ +Yr:
Received__:.;.........:.....191.�..,....c . L.1...fit........... ,.......... Sexton
Name of Cemetery. .........._......:y.....'...:. ...Add%ss.: `:: _......:..
3e.&W-16—LOL'1] F. W" CO., ST. PALL ■
aJt
NOTICE TO UNDERTAKERS
This blank constitutes a Registrar's "Burial Permit" or "Removal Permit" according
to the manner in which it is filled out by the Registrar.
As a Registrar's Burial Permit, this blank most be obtained by the undertaker before
any disposition is made of the body. It is the duty of the undertaker to have a certificate
of death properly filled out with the personal and statistical facts required by law, to
present it to the attending ph sician for his certificate as to cause of death, and then to
file the complete certificate of death with the Registrar of the district where the death
occurred. It is illegal tobury a body in this state unless it is accompanied by a regular
Burial or Removal Permit.
As a Registrar's Removal Permit, this blank must be obtained from the Registrar,
as stated above, presented by the undertaker to the Agent of the Transportation Com-
pany, and be attached by the latter to the boa containing the body. The Removal Permit
it act a -Transit Pes'atit. The ttec, suppiitxi io-cent almers by the State Board arvirlOW,
provides for a statement of the proper preparation of the body for transportation, signed
by the Health Officer. This Transportation Permit also contains a Removal Permit.
No Transit Permit can be issued by any Health Officer, or accepted by the Agent of any
Transportation Company in Minnesota unless a Registrar's Removal Permit forms part
of it, or bas previously been issued by the registrar of deaths.
ISSUE OF PERMITS BY SUB -REGISTRARS
A licensed embalmer, holding an unrevoked certificate of authority from the State
Board of Health to act as a sub -registrar of deaths, has the right to issue this permit to
himself for banal or removal, under the same restrictions as those governing
its issue by the local registrar, except in cities and villages which have
a local ordinance requiring that all burial permits and removal permits be issued by the
local registrar. The certificate of death, fully made out in ink, and signed by informant
and physician, most be in sub -registrar's possession before he issues the burial or removal
permit, and the death certificate must be delivered by the sub -registrar within five days
to the local registrar of the district where the death occurred. The local registrar m a
city is the health officer; in a village, the recorder; in a township, the town clerk.