Burial PermitThis permit serves for a burial permit at destitution
PLACE F DEATH except where local ordinance requires lonl permit
STATE OF MINNESOTA
County_ REQISTRAWS
Township
OR No
Village
CiOR
ty - Permit for Burial orR emoval
Date o ea // — /-19yS
Full nam Ageyrs.
Sex • ... _ _I Place of birth bv$- flL.i
Medical /
attendant Ae
Place of burial, removal
Conv Name of Cent
Und Address
A certifi to of death having been filed insues with the
ffice in ace
laws of Minnesota, I hereby authorize the of the
(Burial or RemovalTJ
body of deceased person as stated above. In case of death from a dangerous
communicable disease, the burial or removal must be conducted accord' to the
rules of the state and local board ofkealth. /,., W 7�
-Write "BurWd or "Remover' as the rase may be. Burial permits n%fstrbe delivered by the
undertaker to the sexton. Removal permits must be given to the agent of traoaportati o company.
and attached by him to box containing body. Sub -registrars will write "Sub" before the word.
- Regbtrar of Deaths' and "Licensed Embalmer N ' below, always giving number
of license. Fine or imprisoament for receiving a body for burial without permit
Received 19— Seaton
Name of Cemetery Address
—
Thi. form may be used for duinterment•reinterment in annordanee with Regulation 23