Burial PermitSATE OF MINNES
TA
DEPARTMENT OF HEn° LTH Burial - Removal - Transit Permit
Section of Vital Statistics
NAME OF DECEASED DATE OF DEATH
AGB
PLACE OF DEATH (City villrre or
�pc-z
Permit ND 2
DEATH COMMUNICABLE?
' Ys La Ne
(Couty)
METHOD OF DISPOSAL: PLACE OF DISPOSITION (Nu, of e.r..tar a er mwotorr) (CIty. VOID w Towz.b1F. Comtr. Ste")
® BURIAL CREMATION
aeaovAL OTHSR (.verlf,) Chanhassen Twp. Cemetery Carver County
SIGNATURE O MORTICLN _Q FUNERAL DIRECTOR BUSINESS ADDRESS
A ae0linq of loth bevy been filed as reeldred by 4w. Dee avian 6 hereby ffirw to di.F.so of tido Mit.
SIGNA" OF REGISTRAR// (CIty, vmYo or tewWlp (C.®ty) I DATE ISSUED
OF CONVEYANCE
AUTHORIZED DISPOSITION A8 STATED BIGNAtURB OF BB270N OR CnU#=y OFFICIAL
vasa aaa-aa. ov
ABOVE OCCURRED ON: (lloN)
6-11-63 2k1 BK5 Order No. 85280