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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