Burial PermitBurial - Removal - Transit Permit
Permit W 58.
NAA4E OP DECEASED
DATE OF DEATH
DEATH CDMMUNICABLE+
Morison Buell
Jan. 27, 2000
YES 0No
AGE
PLACE OF DEATH ICITY. VILLAGE OR TOWNIMP ICOUNTI
Male 79
I
Chaska, MN Carver
OF DIS OSAL:
PLACE OI DISPOSITION INAME OF CEMETERY OR CREMATORY[ [CITY. VIWOE OR TOIEIYMI.. CIXINTY.fTIITE
BURIAL CREMATION
F]Ctlantlassen
Pioneer
❑ REMOVAL ❑ OTHER [SPECIFY)
Chanhassen, Carver, MN
Cemetery
EI�QNK OF ,A7 AN NNllt ll L
n
SIN ADDRESS Bertas Funeral Home
200 West Third Street Chaska MN 55318
A certific to of death having been filed as required by law, permission is hereby given to dispose of this body.
SIONATYPIK OF M: 3 51 CITT. VILLAGE OR TOW HI. Ccu T TITLE
DA I
�r'L (!L� Chaska Carver Sub -re istrar
1-31-0
IN CNA OF CONVEYANCE
_7
AUTHORIZED DISPOSITION
SIGNATURE OF S HTO OR RY OFFICIAL
RECEIV D
AS STATED ABOVE
OCCURRED ON: [OATS)
H E-00113-03 (7/84)
This form provided by the Minnesota Department of Health. Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar