Burial Permitl
Burial - Rerneval- Transit Perrntt Perron No 12292003
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE'
Dolores Maxine Ziegler
December 29, 2003
❑M Q W
sex
AGE
PLACE OF DEATH tI=( VAlAOE oR TOMMMry ICG
Female
75
Chanhassen, Minnesota Carver
METHOD OF DISPOSAL
PLACE OF OISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUNTY, STATE)
aBURNL ❑CREMATION
Chanhassen Pioneer Cemetery
❑REMOI* R OTHVNa.acrn
Chanhassen, Carver ,MN
_7 OF TIC OR FUN RECTOR
BUSINESS ADDRESS
7Rt
520 Second Street Excelsior MN 55331
A (Ca o
h having bee
ed as required by law, permission is hereby given to dispose of this body.
SKIN RE OF ISTRAFY
PW. ValIWi MI TDIMOlI ICGIRITT7 Unix)
DATE ISSUED
xcelsior Hennepin Sub-registar
12/31/20
sro of
AUTHORIZED DISPOSInON
SMINATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE Jan 3 2009
OCCURRED ON 30ATIn r
HE -00113-03 (7194)
Orlglnal—Place of Disposition Copy—Sub Registrar