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Burial Permit
STATE OF MINNESOTA DEPARTMENT OF HEALTH Burial - Removal - Transit Permit Section of Vital Statistics Permit No NAR OF DECEASED DATE OF DEATH DEATH COMMUNICABLE} Herbert C. Wagner (June 28, 1965 I El v. )U N. Sm[ AGB PLACE OF DEATH (CityVDL{. w T.wn.biF) (Comb) Pale 192 Shakopee, Minn. METHOD OF DISPOSAL: I PLACE OF DISPOSITION (Neem of 0011 WY r er.ro.t. Y) (Cib. VULK .r Tewn.hip. Comb, state) © BURIAL CREMATION Chanhassen Cemetery Chanhassen Twp., Carver Co., Minn. n REMOVAL ❑ OTHER (,df,) SIGNATURE OF MORTICIAN OR FUNERAL DI OB BUSINESS ADDRESS artinab Jath bnsNt been flied u rcynir.d L.rebs ■loon b dl y of film bods. SIGNATURE CIS riiFhn (Ceeb) (DATE I30ED Chaska, Minn. June , 1965VUI OF PHESObr* CHARGE dq CONVEYANCE AUTHORIZED DISPOSITION AS STATED I By.N V M/AHOVB OCCURREDON: (Dab) - I 9u�......—.. ycb 6-11-63 2M BKS Ord.r No.85i80 �®