Burial PermitBurial• Removal- Transit Perm itof4;0(0./ Permit No.
NANIE OF DECEASEDDATE OF DEATH DEATH COMMUNIGBLET
8 Month Helen Hillier (Baby Girl) ❑YE, ®No
-12-1991
RACE OF cli CITY, VIU I GE OM TWYl1ENIP 12 (CgINTY
Female --- Riverside, California Riverside County
METHOD OF DISPOi PLACE OF DISPOSITION £NAME OF CEMETERY OM CREMATORY£ [CITY, VILLAG OM T 111P, CCYM,Y,,T1ME
® BURIAL ❑ CREMATION
❑REMOVAL❑OTHER(sPEcIPY) Chanhassen Pioneer Cemetery, Chanhassen, MN. Carver Co.
SIGNATUR MORTICIAN OR NERAL DIRECTOR BUSINESS ADDRESS
_
72 /1 520 Second Street, Excelsior, MN. 55331
A certificate of death having been filed as required by I vq, pernni cion is hereby given to dispose of this body.
51 NA R GI - LITY, VILLgp6'OR TOrIMNI C TLE DATE ISSUED
6�..�- Excelsior. MN. Hennepin Co. Sub Reeistrar 12-18-199
OCCURRED ON: [DATE)
H E-00113-03 (7/84)
This form provided by the Minnesota Department of Health, Se of Vit tatistics Original—Place of Disposition Copy—Sub Registrar