Burial PermitMINNESOTA DEPARTMENT OF HEALTH
Division of Vital Statistics
Registrar's No
Permitfor Burial or Removal
A death certificate as required by Minnesota Statutes 1945, Section 144.191,
having been filed in my office, permission is hereby granted for the disposition
as indicated below of the remains of:
NAME
SES
AGE
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PLACEOF DEATH
DATE OF DEATH
IHTHPLACE
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(Sim. or Couuty) (ayt" Vil. or Iota,)
law)
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CAUSE OF DEATH MEDICAL ATTENDANT
DISEASE:
COMMUNICABLE ❑ OR NON -COMMUNICABLE f8. �'n
o NE "g,
FUNERAL DIRECTOR OR EMBALMER
ADW
LICENSE NO.
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NATURE OF DISPOSITION:
PLACE OF DISPOSITION-
PROPOSED
REMOVAL Ci
GRAN N.4S S .✓ /WP
DATE
re
BURIAL,K CREMATION [II
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VETERAN'!
YES E
NO
NAME
This form may be used for disinterment -reinterment in aceordonee with Regulation 48. . me '� `�+
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