Burial PermitSA. _ Burial - Removal -Transit Permit Permit No. 18242(1(11
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Agnes Geneivieve Anderson
August 24, 2001
❑YU X❑ No
SEX
AGE
PLACEOFDEATH (C",VILUGEORTOMSHIP) (COUNTY)
Female
1 86
St. Louis Park Hennepin
METHOD OF DISPOSAL
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUNTY, STATE)
BURIAL CREMATION
Pioneer Cemetery
0 REMOVAL Ej OTHERISFECIFY)
Chanhassen, Carver , Minnesota
SIGN
EOF RTICE
IR CTO
BUSINESS ADDRESS
520 Second Street Excelsior MN 55331
A certificife of death having been filed as required by law, permission is hereby given to dispose of this body.
SIG T RE OF REGIS
(CfrT, VILucE OR TOWNSMPI (COUNTY) (TOLE)
DATE ISSUED
Excelsior Hennepin Sub -Registrar
8-27-01
SIGNA RE USON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIG RE OF S O CEMETERYOFFICIAL
DATE RECEIVED
AS STATED ABOVE Aug31, 2001
CCCURREDOW(DATE)
HE -00113-03 (7/84) I U U
Original—Place Of Disposition Copy—Sub Registrar