Dept of Public Welfare Division of Public Health RecordForm H 4
Department of Public Welfare --Division of Public Health
05ce of the Local Registrar of Vital Statistics
MINNEAPOLIS, MINNESOTA
Hoon s City Hall,_ 1%/�_ _ /92��' f
A certificate as required by lam having been filed, permission is hereby grated
for the proper disposition of the remains of.•
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Name - - / ` = `> -- 1 Sex/ -Age _ 1
Place of death
Date of death.__f
Cause of death_
Medical Attendant-.
Place of disposition,
FT 7. ..1 .L .: >
Permit
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srNcce
_, Social stat
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