Burial Permity9 STATE OF MESOTAy
DEPARTMENT OF HEALTH Burial - Removal -Transit Permit
Section of Vital Statistics Permit No
NAYS OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
FRED HENRY KELM 6-13-68 El T. ® no
SEX AGE PLACE OF DEATH (City VHiy. er T ---up) (Comb)
Male 79 St. Paul, Ramsey, Minnesota
METHOD OF DISPOSAL: PLACE OF DISPOSITION (Nur of eeseter, er .measle ) (City, VIHa . Tow=WP, Cemty. State)
® BURIAL ❑ CREMATION
ME
Chanhassen Cemetery- Chanhassen, ,Minnesota
BUSINESSADDRESS PETERSON CHkPEL
119Central Buffalo, Minn.
A eertlfieaq of death haei,, heen Ned u requW by law, Fe I k. b hereby F1b dkpa of thk bedr.
SIGNATURE G19 (City. VWY u To.=bA,) (Ceaty) DATE ISSUED
Buffalo Wright 6-16-68
SIGNATURE OP PERSON IN CHARGE OF CONVEYANCE
AVB OCCURR
ED ON: O(Dte) SAT® I SIGNA `�O} SIITON OR C61Q1'E(<T�FF[C/AL I DATE RRC //
10-19-83 2M BKS ORDER NO. 9199E