Burial PermitSTATE OF MINNESOTA
DEPARTMENT OF HEALTH Burial - Removal - Transit Permit
Section of Vital Statistics Registration Permit No- L
NAME OF DECEASED m OJDATE OF DEATH DEATH COMMUNICABLE?
i _ // _' _ _ /i*i_-.Z C{_ r7> M Ys M No
ACE
METHOD OF DISPOSAL: 0
® BURIAL CREMATION
REMOVAL OTHER (sped[y)
SIGNa OF MORTICIAN OR FUNERAL DUM
PLACE OF DEATH (City VBhFo or TwrWp)
PLACE OF DISPOSITION (Slosse oT ao't" s -d
(City. VMue or Ta
Canty, Soto)
/ A sNflub of As9 bpA-F bees, OW s :guired by m.. poesy Y be.&F Find 4 dopes of tbb body.
GNA OF RW.=TRAR (CIty, vmI of T. -Miff` ( ) DATE ISSUE
�-0 �t V 4 1/0-1- -;&3
Hlb�fATURB OF PERSON IN CHARGE OF CONVETANCR
OF SEXTON OR CEMETERY OFFICIAL