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Burial Permit
Burial - Removal - Transit Permit 63 4i Permit o. NAML OF DECEASED DATE OF DEATH DEATH COMMUNICABLE? F. White I August 1, 2002 ❑Y[s ©No Felix SEX AGE PLACE OF DEATH JCIW. VILLAGE OR TOMNIHIv Cat Male 84 Waconia Carver METHOD OF DISPOSAL. FLACE OF DISPOSITION INANE OF C[M[T[RV ON CREMATORY( (CITY, VILLAGE OR TORIIDNIF, CWNTY,[TIIT[ 71 BURIAL CREMATION Chanhassen Pioneer Cemetery, Chanhassen, Carver, M ❑REMOVAL❑ OT1ER(RPECIFY) SfGNA OFAN FUNER O CTOR BUSINESS ADOIESS Bertas FuneralHome r p� 200 West Third Street, Chaska, MN 55318 A certifi ate of death having been filed as required by law, permission is hereby given to dispose of this body. SIGNAT1.4RE OF R GI AR _ CY TILE CITY, VILLGOR TONVWHT AE WN[ DATE ISSUED it Chaska Carver Sub -registrar 8-5-02 SIG OF P ON 1 CHA E OF CONVEYANCE AUTHORIZED DISPOSITON SIG RE OF CEMETERY OFFICI L DATE RECEIVED AS STATED ABOVE �/ / ''''�^^•• OCCURRED ON: (DATE) HE -00113-03 (7/84) This form provided by the Minnesota Department Health, SecIG of Vital S tistics Original—Place of Disposition Copy—Sub Registrar