Burial PermitBurial - Removal - Transit Permit .4.0 (,-L- / Permit No
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Ruth Irene Hall
Oct.22, 1987
OYES �ND
SEX AGE
PLACE OF DEATH (cm, VILLAGE OR TDRNSHIr
(CDUN?Y)
Female 52 Yrs.
I St. Louis Park
Hennepin
M,�ETHOD OF DISPOSAL:
PLACE OF DISPOSInON )NAMi OF CEMETERY OR CREMATORY) (Cr". VILLAGE OR TOVMSHIF� CWNTY,$TATE)
BURIAL ❑ CREMATION
U
❑ REMOVAL ❑ OTHER (SFECIFY)
Chanhassen
Pioneer Cemetery
Chanhassen, Mn.
SIGN RE OF MORTICIAN OR FUNERAL DIRECTOR
BUSINESS ADDRESS
77
520 -2nd. St.,
Excelsior, Mn.
LYA certificate of death having been filed as required by law,
permission is hereby given to dispose of this body.
S17TUR TR
OF REGISAR CITY. VILLAGE OR TORWNIP)
COUNTY
TTUa
DATE ISSUED
__ Excelsior
Hennepin
Sub—Reg.
026987
5 ATVRE OF PERSO IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATURE OF SEXTT
ON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: )DATE)
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