Burial PermitPLACE OF DEATH
Full
of
Disease causing
Medical f_
Place of burial, removal or
Conveyance
�iz.5
�' 3
This permit sera. fora burial permit at destinetbn
except where brat ordi..n rmuirm local permit.
STATE OF MINNESOTA
REGISTRAR'SS
No. .kk7L1
Name
for
date
A certificate of death having been Sled to my
laws of Minnesota, I hereby authorize the
Rh
body of deceased person as stated above. In case 4
communicable disease, the burial or removal must be
rules of the state and local board of hegjjbz?�]
or Removal
7� of the
d•
om a dangerous
according to the
.Write "Burial" or "Removal" m the case may be. Burial permits must be delivered by the
undertaker t. the xx Bemovel permite must be give. to the agent of t.vsportatlon ,..Deny,
and atteebed by him to box m.tainlng body. Sub.regietrare will write "Sub" before the words
'Resist., of Death." cad "Licensed Embabnsr N below, always gM" number
of li.* . bone or bnprieosmeet for re eivina c body for burial witbout Permit
Received -19— 4eaton
Name of Cemetery Address
Thi. form may be need for di.i.termenbreinterme.t i. aewrdapce with Regulation 23