Burial Permitq-/
Burial - Removal -Transit Permit Permit No.
NAME OF DECEASED
DATE OF DIRATH
DEATH COMMUNICABLE?
Edgar A. McClees
July 20, 1986
❑YES Lx FIG
SEX AGE
PLACE OF DEATH (CM, VILLAGE OR TOWNSHIP (CWNTY)
Male 4 Yrs.
Saint Louis Park Hennepin
METHOD OF DISPOSAL:
PLACE OF DISPOSITION (NAME OF CEMETERY q1 CREMATORY) (CITY. VILLAOE OIIP W WIP, CWHTY,SDME)
® BURIAL ❑ CREMATION
Chanhassen Cemetery Chanhasseq, Carve;,Mn.
❑REMOVAL❑ OTHER(SPECIFY)
SIGN RE OF MORTICIAN OR FUNERAL DIRECTOR
BUSINESS ADORES $
r
520 -2nd. St., Excelsior, Mn.
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
5 RE OFR GISTRAR CITv, VIUAGE OR TOWNSHIP (cOONfv =E
DATE ISSUED
l rr Excelsior Hennepin Sub -Reg.
1 7-24-1986
ATVRE OF PERSON IN CHARGE OF CONVEYANCE
AUTHORIZED 0115P051"014
SIGNATURE OF SEXTON OR Y OFFICIAL
DATE RECEIVED
AS SIATED ABOVE
OCCURRID ON: (oArE)
HE -00113-03 (7/84)
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Sub Reclsirar