Burial Permite13, g 52%
STATE OF MESOTA
DEPARTMENT OF HEALTH Burial - Removal - Transit Permit
Section of Vital Statistics Permit No
NAME OF DECHABED DATE OF DEATH DEATH COMMUNICABLE?
Eric C. Gimtzel I Oct. 1 1 ❑ Y. ® Ne
SEX AGB PLACE OF DEATH (City VIW{e or T...hip) (Comb)
Male 4 Months Minneapolis H nnPnin
METHOD OF DISPOSAL: PLACE OF DISPOSITION (Nps. of eo.ta weneuton) (Citi, VIWfo . Tewn.htp. Coety. St.")
® BURIAL El CREMATION
eEYov*L ❑ OTHER (.p.afy) Chanhassen Township Cemetery Carver, Min
SIGNA7 BUSINESS ADDRESS
♦ eertlfipb of doth haring bee filed u reypind b, I... grsisiop I. hereby fire to dip of dd, bo.
SWATURE O, REGISTRAR
n .C/ (Cib. vffl o or TO....hip) (Cooly) DATE ISSUED
�L _ _ AJ M KrM4EAPOLTS PSA I no -r on ?nro
PERSON ni CHARGE OF
STATED I SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
10-10-05 2M BKS ONOEF NO. 91348