Burial PermitPLACE OF DEATH
County Hennepin
Towaship
on
Village Excelsior
/7, F
Thi. permit serves for a burial permit at destination
except where local ordinance reouiree local permit.
STATE OF MINNESOTA
REGISTR.AWS
Permit for Burial or Removal
Date of death Jan. 29, 19t8
Full name Arthur Burt P.vman AAQQe 77
Sex Male Place of birthCarver County Lu nranTiassnyll 'sp.
Disease causing death Cerebral Hemorrhage
Medical1MiProposed date of
attendant) lton Seifert burialorremoval} Jan. 31, 19948
Place of burial, removal or cremation Chanhassen Tway Minnesota
(City, Village or Township)
Conveyance used Auto Name of Cemetery Chanhassen
Undertaker Davies Address Minneapolis _
A certificate of death having been filed in myU�ce in accordance with the
laws of Minnesota, I hereby authorize the R��+ of the
bodyof deceased (Burial or Remo..lry
person as stated above. In case of death from a dangerous
communicable disease, the burial or remoyal, st be conducted according to the
rules of the state and local board of lth
(Registrar of IMatha)
Dated Jan. 31. 19'— Sub. Re¢.
Official Tale
`write "Burial" or "Bemovel" as the raae may be. Burial permmoat oat be delivered by the
undertaker w the sexton. R®oval permits moat ba elven to the agent of tran.portatton oumpauy,
and attached by him to box containing body. Suwill write Sub" before the word.
Registrar of Death." and Lieeoeed Embalmer NO.J._' belowalways giving number
of lieen.e. Fyne or imprisonment for receiving a body for burial without permit.
Received tg_ Caston
Name of Cemetery Address
Thi. form may be used for disinterment- reinterment in aemrda eae wnh Regulation 23.