Burial PermitBurial - Removal - Transit Permit
Permit No.lq b
NAME OF DECEASED
DATE OF DEATN
OG7N CDAIAUNICABLET
Margaret C. Wagner
Dec. 26, 1999�Yo
MR'
5 X
qG
LACE OF DEA CITY, VILLAGE OR TOE'NENIe COURTT
Female
93
Shakopee, MN Scott
ETH00 OF DISPOSAL;
PLACE OF DISPOSITIC IN (NAME OF CEMETERY OR CREMATORY( (CITY, VII.YOEFX OR TO�NEMIF. COYN}Y,arwTE
BURIAL
❑CREMATION
Chanhassen Pioneer Cemetery, Chanhassen, Carver, MN
❑ REMOVAL
[] OTHER IaFecIFYI
A ,IM IAN FUN RAL DIRECTOR
BUSINESS ADDRESS
Bertas Funeral Home
iG w12QO
West Third Street. Chaska MN 55318
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SIGNAT9RE OF REGWMA CITY, VILLAGE OR TOWNENIP co"7 TLE
DATE ISSU
Chaska Carver Sub -registrar
12-28-99
SlcrATU"M OF FAIRSCIN IN CHAIRGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNA RE OF SEXTONPR CEMETERY OFFIC IAP
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (GATE) 1
/ G `
I�
HE -0011303 M84)
This form provided bV the Minnesota Department o Health, Sec - of Vital Statistics Original—Place of Disposition Copy—Sub Registrar