Burial PermitSTATE OF MINNESOTA '`� . 4
DEPARTMENT OF HEALTH Burial - Removal - Transit Permit
Section of Vital Statistics Registration Permit No
NAME OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
Hattie Elva Wi i arm FPh _ � r; 1 CM7L I n Ye P1 No
BEE AGEPLACE OF DEATH (Chy VUI&so or TswuNp) - -- (Cama)
Female 90 Years Excelsior Hpj4r:e
METHOD OF DISPOSAL. I PLACE OF DISPOSITION (Nu, of erotary w A oo th ) (CBy. VIWW. or To p. Comte. State)
® BURIAL CREMATION
REMOVAL OTHER (.,deify) Chanhassen Cemetery Carver, Minn.
SIGN OF MORTICIAN OB FUNERAL DIRECTOR BUSINESS ADDRESS
77 441, 520 -2nd. St., Excelsior, Minn.
♦ eerHOrAh of deth bayhF b,,o fUW u eeyalyd by hw. FeMbWoe 6 hereby ffl o. to diapwa of Oda bady.
UEE OF REGIS (CRY, (CI4. VDhF, or Town") (Cdoty) I DATE ISSUED
♦ Excelsior Or Henn 4-1-_1976
A GNATURR OF PERSON IN CHARGE OF CONVEYANCE
ADTHUNIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
AED I DATE 86C
ABOVE OCCURRON;(Do")