Burial PermitSTATE OF
ESOTA
DEPARTMENMINNHEALTH Burial - Removal -Tm" Permit// e/, 3
Section of Vital Statistics Permit No
NAME OF DECEASED �NZL�� DATE OF DEATH DEATH COMMUNICABLE?
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SSZ AGE PLACE OF DEATH (CRY
METHOD OF DISPOSAL: PLACH OF DISPOSITION t (Nus
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BURIAL CREMATION
REMOVAL❑ OTHER (M.CifT)
SIGN OF MORTICIAN OR FUNERAL DIRECTORBQSITY ADDRESS G ��
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SIGNATURE OF (City. Visa-.riA�-/icy) /J (Cavy)I DATE ISSUED
SIGNATURE O SRSON IN CHARDS OF CONVEYANCE O f � 9 arT. / Gt
SIGNATURE OF SIUMN OE ce MM OMCUL
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