Burial Permit3 -
Burial -Removal -Transit Permit Permit No.
N�K OF DECEASED -DATE OF DEATH
DEATH COMMUNICABLET
Gordon Donald Smida August 19, 1999
❑YES
®NO
A E
MACE OF DEATH cl Tv, vILLAGc OR TOw SHIP (COUNTY)
Female 66
Chanhassen Minnesota Carver Count,
OD OF d5 OSAL:LACE
OF DISPOSITION INAME OF CEMETERV OR CRCMATORY) (CITY, vIWOi OR NIP, COYIRY,fTIRt)
❑ BURIAL ElCREMATIONPioneer
Cemetery, Chanhassen, Minnesota, Carver County
OREMOVAL N OTtER IsvE"" Urn Burial
OF M CIAN ON.FUNERAL DIRECTOR
BUSINESS ADDRESS
013058
520 Second Street Excelsior Minnesota
A c r c o ath WavVg been filed as required by law, permission is hereby given to dispose of this body.
A REGI AR ^ CITY, VILLAGE OR TOWNRHIv CWNTY TITLE
DATE ISSUED
aExcelsior Hennepin -Re
110/5/99
51 A RE O CHARGE OF ANCE
AUTHORIZED OISPOSITION /O
STATIED
FFICIAL
OF;n EMERY OFFICIAL
DE RECEIVED
yS
OffOCCURRED
a
-iLaz
la99�
HE -00113-03 (7/86)
This form provided by the Minnesota Department of earth, Section Lv6ibsl Statistics Original—Place of Disposition Copy—Sub Registrar