Burial PermitX,1� i 1. �
STATE OF MINNESOTA
DEPARTMENT OF HEALTH Burial - Removal -Transit Permit pest No.. `f 8
Section of Vital Statistics
NANS OF DECEASED / DATE OF DEATH p DEATH COMMUNICABLET
✓ er C TT {�. )a/ I 3 — (r0 1:1Yee No
BRZ A S PLAOU OF DEATH (CIty ""-- '- T-- ) .(/County)
9,0 LL,., . 1 M.AI.i, A,os L / 5 flF.✓A/ P/ N
HETHOD OF DISPOSAL: I PLACE OF DISPOSITION (Na,ne of euoloq met) (CW,, Village "^--•alp r '- grate)
BURIAL El CRENATION
REMOVAL ❑ OTHER (epedf,) Gey- G
SIGNAOF MO87ICIAN 8 FUNERAL DIRECTOR BUSINESS ADDRESS
A certificate of death having been HW as re,nired b, law, peralceloa is hereby given to dim. of thin bad,.
SICNA OF REGISTRAR (ew, Village eMFwrhtjL(c�go') qq.��TB ISSUED
0 r /.� L - 9- r- 17 f L/_ / _ /a/o
OF PERSON IN CHARGE OF
AUTHORIZED DISPOSITION AS STATED SIGNATURE OF SEXTON OR CEMETERY OFFICIALI VATS REGAIVCD
ABOVE OCCURRED ON: (Data)
10-I8-66 ZM BKS ORDER No. 91346 O