Burial PermitPA
2
Burial - Removal - Transit Permit
Pe ft ND. 21031
NAME OF DECEASED
DATE OF DEATHDEATH
COYYUNICABLE7
Gordon Ralph Anderson
February 10,
1997
❑YES Q NO
SEX AGE
PLACEOFDEATH (rn ,VaUREDRTDwxsw)
(r Yl
Male 40
Wayzata
Hennepin
YETMOD OF DISPOSAL
PLACE OF DISPOSITION (IMAEOF�MILRFLATORY)
(CITY, VALAOE OR T0IYIMIIP, COI .STATEI
171BURULL CREMATION
Chanhassen Pioneer Cemetery
FIRE" AL MOTHER(SPECIFY)
Chanhassen, Carver ,MN
RE OF MORTICI& OR FUNVIAL DIRECTO
BUSINESS ADDRESS
16394 Glory Lane Eden Prairie
MN
A cert' a eath having bee
led as required by law, permission is hereby given to dispose of this body.
RE OF S
NSD', VAlAOE OR TOYa6NRI IOODRrn
(TITLE)
DATE ISSUED
Eden
Prairie Hennepin
Sub -Registrar
02/12/1997
SIG URE OF P ON ARGE OF CONVEY
AUTHORIZED DISPOSITION
SIGNATURE OF CEM OF
DATE REC9VED
AS STATED ABOVE Feb 13, 1997
OCCURRED ON :(DAT)
„��y � y`�
/J
D) l3—%J
HE -00113-03 (7/84) /j
� Original—Place of Disposition Copy—SuD Registry