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Burial Permit¢¢, C ,Utiau-t� / :,I--- Burial -Removal -Transit Permit Permit NAMIE OF DECEASED DATE OF DEATH DEATH COMMUNICABLE? - Verona Adelfa McClees arch 18, 1998 1 11 YES ®No E AGE I PLACE OF MAW CITY, VILLAGE OR TOWNSHIP) (COUNTY] Female 89 St. Louis Park Hennepin ETHOO OF DISPOSAL:PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUrRT,STATE) ® BURIAL © CREMAnON remains Chanhassen Pioneer Cemetery Chanhassen Carver Minnesota ❑ REMOVAL O OTHER (SPECpT) SIGNATURE OF MORTICIAN OR FUNERAL DIRECTOR BUSINESS ADDRESS �,A G _Z 520 2nd St. Excelsior, Minnesota 55331 A certificate of death having been filed as required by law, permission is hereby given to dispose of this body. SIUNAR GISiRAR' CITY, vILUGE OR TOWNSHIP COUNTY (TITLE)DA ISSUED / �� �9e-" Excelsior Hennepin Sb -registrar 3/20/98 SIGMAIVm= Wr PE IN CHARGE OF CONVEYANCE AUTHORIZED DISPOSMON SIGNATV RE OF SE%T OR CEMETERY OFFICIAL DATE RECEIVED AS STATED ABOVE 3 -3G � (/ OCCURRED ON: (OATS) Z - I O HE -00113-03 (7/84) 11 This form provided by the Minnesota Department of Health, S414. of V).1 Statistics Original—Place of Disposition Copy—Sub Registrar