Burial PermitBurial - Removal - Transit Permit b,,� / /9Psnnit No.
NAME OFDECEASED
DATE OF DEATH
DEATH COAMUNICABLEt
GLADYS M.
KNAPP
11-4-1990
1:1 T" ®"b
SEX AGE
PLACE OF DEATH CITU, VILLIIOE OR TOROUROPI (cacmmv
Female 1 93
San Diego, California San Diego County
METHOD OF DIS OSAL:
PLACE OF DISPOSITION (NAM[ OF CEMET(RY OR CREA,ATR
OYI (CITY, VILLAGR OR TOrIi111P, COYN,T,RTAT6
BURIAL a CREMATION
Cremation - San Diego, Calif.
❑ REMOVAL ❑ OTHER (SPEC FYI
InUrnment - Chanhassen Pioneer Cemetery, Chanhassen, MN.
SI NATURE MORT AN OR NERAL DIRECTOR
BUSINESS ADDRESS
520 Second Street, Excelsior, MN. 55331
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
-HIP
5 NA REGISTRAR
CITY, VILLAGE OR VO COONTY
DATE ISSUE
celsior, MN. Hennepin Co. Sub. Registrar
8-7-1991
SIG A RE F ERSONIIN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SI ATURE OF SEXTON OR CEMETERY OFFICIAL
OEM RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE(
HE -00113-03 (7/84) f U 0
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar