Burial PermitBurial' Removal' Transit Permit buL"w 4 Pe mit No.
AMOF OECEASKO
DATE OF DEATH
DEA'Itl COM MCABLET
Richard B. L n 1/30/93
EI -Ess QX —
SE% AGE
PLACE OF DEA (CITY, vEEAGE OR'rC. IPl Ccii
Male 88
Weslaco, Texas Hidalgo
METHOD OF DISPOSAL:
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY( (CITY, VILLAGE OR TORNSHIP, Couii"ATE)
®BURIAL ❑CREMATION
Pioneer Cemetery
❑ REMOVAL ❑ OTHER (SPECIFYi
Chanhassen, MN Carver County
SIGNA MORTICIAN OR FUN AL DIRECTOR
BUSINESS ADDRESS'S 'd;. o
'`'
t
-�-�
Huber Funeral Home, 520 2nd St., Excelsior, MN 55331
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SIGN OF REGI
CITY, Vi OR TGRN,NIP COONTY TLE
DATE ISSUED
"�
Excelsior, MN Hennepin Sub -Registrar
2/4/93
SIGNATURE OF PERSON N CHARGE OF VEYANCE
AUTHORIZED DISPOSITON
SIGNATURE OF SEXTAN OR CEMETERY OFFICIAL
s
AS STATED ABOVE
OCCURRED ON: IOMKI
1 ,(
G
—5� / 3
7-VGI IJ'VJ k"a.' /
This form provided by the Minnesota Department of Health„section of VAJI Statistics Original—Place of Disposition Copy—Sub Registrar