Burial PermitBurial • Removal • Transit Permit
Permit No. / �/.
D
DATE OF DEATH
DEltT11 CWAUMu6LEi
VERNON WAGNER
March 5,1999
❑Yq ®Np
SEX AGE PLACE ATH ICIW. VILLAGE OR TOWNSHIP 1COYRT'
Male 1 86 Fairview Southdale Hos ital Edina Henne in MN.
OD OF DIS OSAL:
PLACE OF DISPOSITION (NAME OF CEMETERY OR CRR,ATORY) )CITY VILLAOi OR tOMNaNIF� COUNT,STATE
® BURIAL a CREMATION
OREMOVAL❑ OTHER(SPECIFY)
Chanhassen Pioneer Cemetery, Chanhassen, Carver, Minnesota
SIG R O OR ISLINERAL DIRECTOR
BUSINESS ADDRESS Morris Nilsen Funeral Chapel
6527 Portland Ave. S. Richfield MN. 55423
rtificate of death having been filed as required by law, permission is hereby given to dispose of this body.
51 R I Icn,,. vlwu OR TORMN"' cOIM,Y TLE
Iffil/
Q� Richfield, Hennepin, MN. Sub. Reg.
3/6/99
I N OF I.RISON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE)
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