Burial PermitBurial - Removal -Transit Permit cv?;t /3 . f/ Permit
NAA4E OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Barbara J. Skelton
Nov. 27, 1987
Elu gj1 No
SE AGEPLACE
04' CEATH (CITY, VILLAGE OR TOWNSHIP (COUNTY)
Female 55
Minnetonka Hennepin
METHOD OF qs OSAL.
PLACE OF DISPOSITION LA
(NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COU T ,STAT£)
® BURIAL ❑ CREMATION
Fj REMOVAL❑ OTHER(SPECIFY)
Chanhassen Cemetery Chanhassen Carver Minnesota
SIGNA RE MORTICI IFU ERAL DIRECTOR
BUSINESS ADDRESS
520 2nd Excelsior, MN. 55331
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SIGR REGISTRAR CITY, VILLAGE OR TOWNSHIP) CcuwY (nTLE
DATE ISSUED
Excelsior Hennepin Sub -Reg.
11-27-87
IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSInSIGNATURE
ON
OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
As STATED ABOVE
p
OCCURRED ON: (DATE) N0✓. .� /
H E-00113-03 (7/84)
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar