Burial PermitBurial - Removal - Transit - Permit
Permit No
NAME OF DECEASED -
DATE OF DEATH
DEATH COMMUNICABLE?
Ronald R. Rice
Feb. 10, 200
Yes )tj No
SEXAGECITY.
PLACE OF DEATH (STREET ADDRESS; VILLAGE. OR TOWNSHIP; COUNTY)
Male
36
26224 150th Street, Zimmerman, Sherburne
METHOD OF DISPOSAL
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY; CRY, VILLAGE, OR TOWNSHIP; COUNTY, STATE)
XBurial Cremation
Chanhassen Pioneer Cemetery
.. Removal .. Other(specify)
Chanhassen, Carver, MN
SIGNATURE OF MORTICIAN ORF NE DIRECTO
BUSINESS ADDRESS
2/tet
Bertas Funeral Home
�il
200 West Third Street, Chaska, MN 55318
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SIGNATURE OF REGISTRAR
CITY. VILLAGE. OR TOWNSHIP; COUNTY, TITLE
DATE ISSUED
4 jr"
Chaska Carver Sub—registrar
2-15-05
I - OF PERSOYIN CHARGE OF CONVEYANCE
IZED DISPOSITION AS STATED ABOVE OCCURRED ON:
SIGNATURE OF SEXTON OR C ERY OFFICIAL
DATE RECEIVED
):
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MEm0011 a Departmentt of Heats. Off" of the State Registrar (�