Burial PermitC
Burial• Removal• Transit Permit
Permit No.Q &4A-3
N OF
ESED_
DATE OF AlH
Dl COMMUNICA i
❑ YES ry0
5
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F A (CITY, VILLAGE OR TOWryIHIPI
(COuNvY)
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F DISP L.
BURIAL ❑CREMATION
PLACE OF DISPfllr!DN (1A IE OF CEM CRKNATORY ITY, VI Gi ORTOWNSHIP, couW1,STATE)
, / h' N<s��C'N 'O
\V/ r UCi r
EMOVAL � OTHER (SPECIFY)
SI Nq R OF MORTICI UNERAL DIRECTOR BUSINESS ADOR
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SS3
A Certific a of death having been filed as required by law, permission is hereby given to dispose of this body.
RE OF I
CITY, OWNSHIP COUNTY
TYLE DA Is5 D
Herne in
De ut
RE N C AR E
CONVE ANCE
AUTHORIZED DISPOSITION
SIGNATVRE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOV E
OCCURRED ON: (DATE)
HE -00113-03 (7/86)
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar