Burial PermitSTATE OF
DEPARTMENT OF HEAT TH Burial - Removal - Transit Permit
Section of Vital Statistics
Permit No --V
NAME OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
Mins C. Maxwell April 12, 1959 I ❑ Yee No
SEX COLOR OR RACE AGE PLACE OF DEATH (GODEMOM Town") (Coaaty)
Female I White �5 Zra� Chanhaasen Carver
METHOD OF DISPOSAL: PLACE OF DISPOSITION (Nue of ceeaetey, or see ftey) (City, Vmq. or Towvhip, County, State)
® BURIAL ❑ CREMATION
REMOVAL OTHER (epeeiDy) Chanhassen Township Cemetery Carver Minn.
SIGNAT O ICIAN ORF DIRECTOR BUSINESS ADDRESS
520 -2nd. St. Excelsior, Minn.
A eerHHmfe of doth h.yfaa been Died u repaired by I.w, pervWloa 1. hereby irm to din,oee of this body.
SI OF REGIS mp. Vm.pe .JCIE230) (Canty) DATE ISSUED
Excelsior Hennepin fine 23&1959
'IrIF URE OF PERSON M CHARGE OF CONVEYANCE
AUTHORISED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL I DATE RECEIVED
ABOVE OCCURRED ON: (D.U)
9-10-64 1500 Bka. Rep. No, 42
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