Burial PermitSTATE OF MESA
DEPARTMENT OF HEALTH BurW - Remeral -Tnink Permit
Section of Vital Statistics Registration Permit No
NAME OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
Darlene M. Andrus I Feb. 3, 1981 A Na
SEX AGB PLACE OF DEATH (CI, VUIy .r Tw..hl.) (C.ub)
Female I 51 Years I Chaska Carver_
METHOD OF DISPOSAL: I PLACE OF DISPOSITION (Na-..? .v.Nrs w .n-.I.rs) (CHs. VUiy..r T. -..M6 C.o,. Slab)
® BURIAL CREMATION
REMOVAL OTHER (.F.IIIs) Chanhassen Tovp. Cem. Carver Minn.
BIC,N�TURE OF MORTIC NOB PUNEBAL DIRECTOR BUSINESS ADDRESS
; f�L1 520 0R
St. Excelsior Mn.
T • srtlllub d _M h.s4. h... ION o r .IrN by i.-. Per -Y.1.. b h -.hs .Ism b +l. of E+b body.
SI'JLTURE OF RRGISTRA)R (GMs. VDI.a. .r Tw..Mp) IC...,) I DATE ISSUED
OF PERSON IN CHARGE OF
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
ABOVE OCCURRED ON:(D.b)