Burial Permit,4t 77, ;-
STATE
STATE OF MINNESOTA p ���
DEPARTMENT OF HEALTH Burial - Removal-Trmit Permit
Section of Vital Statistics Permit No- 231
NAME OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
Clara Kerr Poore July 242 1963 ElT.❑x No
SHE COLOR OR RACE AG8 PLACE OF DEATH TO Vilgo or> (Covoty)
Female I White I$5 yrslo Excelsior Hennspin
METHOD OF DISPOSAL: PLACE OF DISPOSITION (N0000 (otor7 or erouatnq) (City, VIR"o or Tpwdhip, C000ty, Stow
BURIAL ❑ CREMATION
aEMovwL ❑ oTRER (rprHr> Chanhassen Twp. Carver County Minn.
E1GNA OF ORTICIAN OR FUNERAL DIRECTOR BUSINESS ADDRESS
T �./ / I 520 -2nd St Excelsior, Yinn.
A earBnwto of drth hprlo, loev fDed m reyolred by low, pomi io- 1. herehr Firm to dtp of SJo hod?.
SIGN EE F RECISTRAE (City. Vid". or Tewo•hip) (Coomty) DATE ISSUED
T, /r Excelsior Hennepin I July 26,1963
SI OF PERSON IN -CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
ABOVE OCCURRED ON: (Daft)
5-14-62 1500 Bks. Order No. 82850
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