Burial PermitBurial • Removal • Transit Permit
Permit No.
HE -00113-03 (7/84)
This form provided by the Minnesota Department o Health, Sect U of V i[ tatistics Original—Place of Disposition Copy—Sub Registrar
DATE OF DKAT
DEATH COMMUNICABLE?
CAROLINE ELIZABETH WAGNER
June 22 1995
1 ❑YEa N'
SEX AGE
PLACE OF DEA -1114 CITY, VILLAGE On TOwnaNIF (COUNTY
female 76
Edina Fairview Soenin
iM
OD OF DI$ OSAL:
PLACE OF DISPOSITION (NAME OF CEHE OF CnEMATOR (CITY, VILLAGE OII WMNgm W' T *TA
��
OI PUR1AL ❑CREMATION
Pioneer Cemetery Chanhassen, Carver, Minnesota
OREMOVAL ❑ OTHER IEPCCIFYI
SIGN=N on KU AL DIRECTOR
BU$INESSApORE$S MORRIS NILSEN FUNERAL CHAPEL
6527 Portland Avenue Richfield, MN. 55423
A certificate of cfeaih having been filed as required by law, permission is hereby given to dispose of this body.
R GI AR CITY, VILLAGE On TOWMNIP COUNTY TTLE
DATE ISSU D
Richfield Hennepin SUB REG
6-26-95
RE VF E ON [NfCHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION $IGNA E OF 5
CEMETERY OFFICIAL
DATE RECEIV D
AC$ STATED ABOVE
(p
OCCURRED ON1 (GATE( (O ✓
HE -00113-03 (7/84)
This form provided by the Minnesota Department o Health, Sect U of V i[ tatistics Original—Place of Disposition Copy—Sub Registrar