Burial PermitUrn
Burial - Removal - Transit Permit
Permit N6. -
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NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
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7 0
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YES NO
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SEX
AGE
PLACE OF DEATH (CITY, VILLAGE OR TOWNSHIP) (COUNTY)
N C
METHOD OF DISPOSAL:
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUNTY, STATE)
BURIAL Ll CREMATION
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REMOVAL OTHER (SPECIFY)
1:1
1 YetAI.SIGNATURE
OF "MORTICIAN OR FUNERAL DIRECTOR
BUSINESS ADDRESS f
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SIGNATURE OF REGISTRAR (CITY, VILLAGE OR TOWNSHIP) (COUNTY) (TITLE)
DATE ISSUED
SIGNATURE OF PERSON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATU E OF OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE)
aSEE-T
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HE -00113-03 (7/84)
This form provided by the Minnesota Department of Health, Se4,/On of Vital Statistics Original—Place of Disposition Copy—Sub Registrar