Burial PermitSTATE OF MINNESOTA
DEPARTMENT OF HEALTH
Section of Vital Statistics
a -t s 6 -
Burial - Removal - Transit Permit No. N Li -
REVERSE SIDE GIVES BURIA4REMV YA4Ta[A1YntT
1. NAME OF DECEASED
L DATE OF DEATH DEATH DUH TO
COMMUNICABLE
James Henry Livingston
DISEASE Yea ❑ N. ®
Meet► Jan u" 27 year,19J
PERSONAL
L SEH
d. COLOR OR RACE
$. AGHi.
PLACE OF DEATH (CRy. ViDvpe or Towaahulp) (C.y) (state)
DATA ON
DECEASED
_..., e
c(hlteG�i
$. aiinnespolis Hennepin :ifnn•
METHOD OF
F1PLACE
(Name of Cemetery or Crematory) (Cly, Villose or Towmhip) (Covet]) (stem)
DiBPOSAL: BURIAL CREMATION
OF THIS BURIAL
REMOVAL E] OTHER(specify)-
REMOVAL ON DISPOSAL: Chanhassen Townshir Carver
BICNAT F MORTICIAN ORP DDDSCTOR
BUSINESS ADDRESS
FUNERAL
52C St. Excelsior, drIn.
DIRECTOR
_
-2nd.
.vd/or
o it Is 996&ed that the remain. have MORTICIANe NATURE LICENSE NUMBER AND ADDRESS
MORTICIAN
beebAproperty prepared: /
c -nn
A certifieeta of death haying Leen 1sM abed b7 the Iow• o Miveeeom end .0 Iowa /overeivs the preparaOon and dispaat d (dad ham")
AUTHORI-
b.diee eomPHd I. to dbpae of thb body.
ZATION
TO DIS-
POSE OF
-y} � �p.rmlood"
�...�ym
SIa TUIM OAEG78'TRAR ' a •"�LVr rvebip!..-. _ �(Cs�ey1i n..w���
T �_; k. F.�t-.LYII`1
DAIS ��*� I�57
BODY
Ste. ti+.��..:s``-.•'t"'/'y .. n
/( wvl - -
nv_Yae_
f�'
Month
BODY WAS
DATEI
NAME OF CEMETERY OR CREMATORY LOCATION (City. VHIoge or T..hip) (Comb) (Stam)
DISPOSI-
BURIED ❑
Month Dp Year
TION OF
BODY
CREMATED❑
SIGNATURE OF SEXTON SIGNATURE OF PERSON IN CHARGE OF CONVEYANCE
OTHER (apad4)
REVERSE SIDE GIVES BURIA4REMV YA4Ta[A1YntT
READ CAREFULLY
REGISTRAR: This Burial -Removal -Transit permit may be issued only upon receipt of a death certificate
properly made out. A certificate must be filed for every dead human body including stillbirths before perma-
nent removal, interment or other disposition. *Where Regulations of the State Board of Health require, the
Mortician must certify as to the proper preparation of the body. The stub must be retained in the files of
the registrar.
FUNERAL DIRECTORS: This Burial -Removal -Transit permit is required for every dead human body.
*Regulations of the State Board of Health require in some cases preparation of the body by a Mortician be-
fore you are authorized to take charge.
COMMON CARRIER OFFICIALS: This Burial -Removal -Transit permit will authorize the transportation of
a dead human body when prepared according to the Regulations of the Minnesota State Board of Health.
No other permit is required or authorized. The Burial -Removal -Transit permit shall be enclosed in a strong
envelope and attached to the shipping case or carried by the escort.
MORTICIANS: The Burial -Removal -Transit permit is required for any manner of disposition of a dead
human body. *When embalming is mandatory according to the Regulations of the Minnesota State Board
of Health you must certify that the Regulations have been complied with by personally signing the permit
form.
SEXTON: It is unlawful for any sexton, or person in charge of a cemetery to permit burial or other dis-
position of a dead human body unless it is accompanied by a Burial -Removal -Transit permit. Permits
originating outside of the State of Minnesota must be exchanged for a local permit to bury. Where there
is no sexton, the person in charge shall mail this permit to the State Registrar, St. Paul, Minnesota.
PENALTY FOR VIOLATIONS: Violation of any Regulation of the Board is a misdemeanor.