Burial PermitDEPART. ENT OF HESTATE OF ALTH Burial - Removal - Transit Permit
Section of Vital Statistics Registration Permit No.
NAME OF DECEASED (DATE OF DEATH DEATH COMMUNICABLE}
Charles To Kletzin IMarch 20,1980 ❑ Y. a No
SEX AGB I PLACE OF DEATH (City VHIq• or T...Wp) (C•uty)
Male 177 1 Winsted McLeod
METHOD OF DISPOSAL: PLACE OF DISPOSITION (Name of tn.•t•r, •..n.ptoo) (City. Mils. or T..Idp. Comty. St•t.)
❑x BURIAL ❑ CREMATION
REMOVAL ❑ OTHER(.Pedfy) Chanhassen Cemetery,Chanhassen, Hennepin,Minnesota
BI U OP MO FUNERAL DIRECTOR BUSINESS ADDHB88
Arve A. Grimsmo Winsted Funeral HOme,Box 463,Winsted,Mn 55395
Aardfiu�je.th h.rinp been filed u r .Irad by b-. per.l.iap b b.r.by [Irma b dbpme of We bads.
SI 7UHE f:f (Gley. Vilbe. •r To-..Wp) (Cmty) DATE ISSUED
Winsted McLeod 3/22/80
SIGNATURE Of PERSON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL I
ABOVE OCCURRED ON:(D.b)