Burial PermitBurial - Removal - Transit Permit
Permit No. "112"l
NA MEAF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Douglas Earl Kelm
June 11, 2001
1 ❑'tea 1fl NO
SEX AGE
PLACE OF DEATH ICRP, PILLAGE OR TO—WP)
(COUNTY)
Male 63
Waconia
Carver
METHOD OF DISPOSAL
PLACE OF DISPOSITION(NAME OF CEMETERY OR CREMATORY) (CRY, VILLAGE OR TOWNSHIP, COUNTY. STATE)
BURIAL ❑CREMATION
Pioneer Cemetery
1:1 REMOVAL ❑OTHER(SPECIFn
Chanhassen, Carver ,MN
SIG
URE OF AIO C
R FUN RAL DI GTOR
BUSINESS ADDRESS
l520
Second Street Excelsior MN
55331
A cern ca a of death having been filed as required by law, permission is hereby given to dispose of this body.
SI N RE OF GIS (GTR, KLUGE OR TOWNSHIP) (COUNM
(TIFLE)
DATE ISSUED
Excelsior Hennepin
Sub-Registar
6-12-01
S RE OF SOMIN CHARGE OF'CONVEYANCE
AUTHORIZED DISPOSITION
SI RE OF SE%T YOFFK:IAL
DATE RECEIVED
AS STATED ABOVE
June 14, 2001
4,
OCCURREDON:IDATn
HE -00113-03 (7184)
Original—Place of Disoosdion Copy—Sub Registrar