Burial Permit64�,f .? -7.7
STATE OF TA
DEPARTMENT OF HEALTH Burial - Removal -Transit Permit
Section of Vital Statistics Registration Permit No
NAME OF DECRASED DATE OF DEATH DEATH COMMUNICABLE?
Corrie Poore Ober I Dec. 21, 1981 ❑ T. FA No
SRZ AGE
1PLACE OF DEATH (City Villye er TW
e-ls) ICeubl
Female 171 Yrs. Excelsior Hennepin
METHOD OF DISPOSAL: PLACE OF DISPOSITION (Ns of ereteq er <n-eteO) (City. Vlliese e, T..Mp. Ceeet,. Stek)
BURIAL F1 CREMATION I Chanhassen Cemetery Carver MInn.
REMOVAL— E] OTHER (Wedh)
BIGN= OF MORTICIAN 9� FUNERAL DIRECTOR BUSINESS ADDRESS
T �/ lug 520 -2nd. St., Excelsior, Mn. 55331
I A WrHfkaY H irt► VwF bt fiW Y vee\/,ed by V-. nr bW.. Y Mn►, sire to dh a e( Ob ee&.
BI E OF REGISTER (CHI. Vfll a or T-"") (Ce ty) DATE ISSUED
lam_ Excelsior Hennepin 12-23-1981
B TURK OF PERSON IN CHARGE OF CONVRTANCR
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL I
ABOVE OCCURRED ON: (Dete)