Burial PermitM
Burial _ Ramnval _ Transit Permit
I7�11�f1<YlcYimltl
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
March 23, 2001
❑''�' 0 MO
Ernest Winjum
SEX
AGE
PLACE OF DEATH (CnY.VIuAGE OR TO SHR)
(cola+TVl
Male
86
St. Louis Park
Hennepin
METHOD OF DISPOSAL
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUNTY, STATE)
❑BURIAL CREMATION
Pioneer Cemetery
'
REMOVAL a oTHE=
Urn Burial
Chanhassen, Carver, Minnesota
SIG OF MORTICIAN
FUNERAL DI TOR
BUSINESS ADDRESS
16394 Glory Lane Eden Prairie MN
55344-
A certificat f64th
having be d as required by law, permission is hereby given to dispose of this body.
E OF RE ISTRA
ICRP, NLLAGE OR TONNSHRI (COUNTY)
(TITLE)
DATE ISSUED
Eden Prairie Hennepin
Sub -Registrar
3-24-01
SIGNATURE OFP N 7KGE
OF CONV
AUTHORIZED DISPOSITION 5-8�7.60I
Q&ETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE S rin Burial
p g
OCCURRED ON 3DATE)
HE -00113-03 (7184) l v (/
Original—Place of Disposition Copy—Sub Regislra