Burial PermitCITY OF ST. PAUL 5/ y
No. Department of Public Safety (O J
BUREAU OF HEALTH
DIVISION OF VITAL STATISTICS
DATE MRIGh 5, 19_ 1
PERMIT FOR BURIAL OR REMOVAL
A death certificate as required by Minnesota Statutes 1945, Section 144.161, having been filed in my office,
permission is hereby granted for the disposition as indicated below of the remains of.
NAME, I SEX I AGE
[ary Livingston
OF DEATH DATE OF DEATH
CAUSE OF DEATH MEDICAL ATTENDANT
DISEASE:
COMMUNICABLE ❑ OR NONCOMMUNICABLE 7A C. A. Ingerson Coroner
A.. n -- m u,—An T%.v,,,+,r
FUNERAL DIRECTOR OR EMBALMER
ADDRESS
LICENSE NO.
New Henry Funeral
Home
9t. Paul, Minnesota
NATURE OF DISPOSITION
PLACE OF DISPOSITION
PROPOSED
DATE
BURIAL m
Chanhassen, Minn.
(CEMETERY)
Chanhassen, Hinnesot
REMOVAL ❑
3-6-51
CREMATION ❑
AT
Veteran?
Yes ❑
Registrar .'��•y"�
No ®
Name War
BY C Bo�i[ 7
THIS FORM MAY BE USED FOR DISD.'TERMENT-REINTERMENT IN ACCORDANCE WITH REGULATION 23