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Burial Permit
STATE OF MINNESOTA p''��� DEPARTMENT OF HEALTH Burial - Removal -Transit Permit Section of Vital Statistics Registration Z of .5/, t Ii Permit No. NAYS OF DECEASED DATE OF DEATH DEATH COMMUNICABLE} C. Willard Livingston 3-9-1977 ❑ Te Ne SEX AG6PLACE OF DEATH (City VHhq..r T.-a.Wp) (C.aaty) Male 75 Ball Club. Minnesota R.R. i r.Ass METHOD OF DISPOSAL: IN BURIAL ❑ CREMATION fXj REMOVAL— © OTHER^.nrdfT)�nse PLACE OF DISPOSITION (N..e .f a .ta w mw t. ) (City. VHIaF. e. Te-aahlF. C.aaty. St W) Chanhassen Township Cemetery Chanhassen, Carver Co., Mn. BUSINESS ADDRESS wrtlfloa of dnth ha.lat b e flied u repaired M V-, WrvlwMa 1. Y.r.►1 Fles ft di.D .f thb SIG( A7U11){ Or RrGlVgrn R )? f # ^ _ I, (City, Vilbe. ^r TewWIP) .. — — (C~Y) I DATE ISSUED OF PERSON IN AUTHORIZED DISPOSITION AS STATER bRE OF SEXTON OR CEYETERT OFFICIAL I DATE RECEIVED ABOVE OCCURRED ON;(D.0) 1\