Burial Permit, -;t 3G. /
PLACE OF DEATH STATE OF MINNESOTA
County....... „ REGISTRAR'S
Townshi ��.--s...... No ......... .
i OR
°fie.......- Permit for Burial or Removal
City...__._._...... .. _........ --
ate o eath.............. q�^................ 10..'�
Full N e... _7..? ..... _.- ..... Yrs.
Sea ........ ......................Place of Birth..... b........................
Disease causing death�3. .
Medical i Proposed date o
attendant!..... �.. ... burial or removal.......?.7..19A—
Place of burial ............ .
Place of removal ....... ..............................via......................... .
Undertake r .......................... ddress..., .........
A certificate of death having been filed is ce in accordance with the laws of
Minnesota, I hereby authorize the ........................... ............................of the body
of said deceased (Baml o< Bmovet)
pasoa as stated above.
Dated.. .. a n..tI
719.03.E ...................... .
Official Title