Burial PermitLLM
PLACE OF DEATH
county�—
Township
OR
vabre
C�
G ate of dgs
Full
This permit nerves for a burial permit at destination
except where local ordinance requires local permit.
STATE OF MINNESOTA
REGISTRAR'S
No. / 4 3
Permit for Burial or Removal
Sex V-e-f� _P11#ce of birthA"
Disease causing dea mini
Medical Proposed date
attendant ® rial or remo
Place of burial, Imoval or crematio
Name of
A certillca of death having been filed in
laws of Mirind6ota, I hereby authorize the_
19
IV—/ 19
City, ViL or Twp)
r
In accor4ance with the
of the
body of deceased(Burial or Removal-)
person as stated stove. In case of death from a dangerous eom-
of the ble disease, the burial or removal must be conduCW according to the rules
01 the state and local board of health. n
1/
Dated 19 3g /t�R era�,
Official Title
•W ' 'Burial" or •'Removal" as the case may be. Burial permit. most be delivered by the
uvdert cr to the ecstov. Removal permits must be ev to the agent of transportation core.
pany, and attached b Lim to bo: coutainivg body. bube'st t s d write Sub" before the
words Arty. of ths" sad Licensed Embalmer No. below, always giv-
ing number of license. Fine or imprisonment for receiving y o unal without permit.
Received 19 Sexton
Name of cemetery Address
This form may, he for dlaivtermaat-raintermeat he accadm with Regulatim M