Disposition PermitDECEDENT'S NAME DAV0 ALLEN PAULY
GENDER MALE
DATE OF BTH /AGE 09/04/1960 54
DATE OF DEATH 05/09/2015
GOLDEN LIVING CENTER, EXCELSIOR
PLACE OF DEATH 515 DIVISION STREET
EXCELSIOR, HENNEPIN, [kiflNNESOTA
FUNERAL DIRECTOR FAUL F HUBER�, M, 2 6 6 3
FUNERAL HOME OR HUBER FUNERAL HOME CREj�,/,",IAT�ON L lu! C IjHu 0 9 14
OTHER ENTITY 16394 GLORY LANE
EDEN PRAIRIE MINNESOTA
DISPOSITION FAr.11 ITY
FAIRVIEW CEMETERY ASSOCIATION 0 1
WNNETRSTA MINNESOTA
PLACE OF DISPOSITION �I
PIONEER CMVIETERY QURN BURIAL - DATE
=MMM" S SEN Q HIMMESOTZA CA-AUR=\11-R CO =1 y
According to Minnesota Statutes, section 149A.93, subdivision 3
section 144.221, and Minnesota Rules, part 4601-1500, the fact of
death has been filed with the Office of Vital Records.
Molly Mulcahy Crawford
STATE REGISTRAR
DISPOSITION PERMIT ISSUE DATE 05/11/2015 07:08 PM
(SIGNATURE OF FINAL DISPOSITION FACILITY OFFICIAL)
(PRINT NAME OF FINAL DSPOSITION FACILITY OFF0AL)