Burial PermitPLACE OF DEATH
,5
This hermit serves for a ori5el remit at dem..,
except where local ordinance mQuires local i,erm.-
STATE OF MINNESOTA
REGISTRAR'S
No. 3W
Permit for Burial or Removal
Full nn. IAge _YM
Sex t7rdPla of bird
Disease causing death -
Medical Proposed Ateof I.
attendan rial or rem ival 19 `,%
Place of burial, remova or crematio
(city, Vil. or TF1w )
Conveyance u. Name of Cemete
Undertake ddressC - a„—
A certificate of death having been filed in in ice in acyprdance with the
laws of Minnesota, I hereby authorize the .Y of the
( urlal or Removal•)
body of deceased person as stated above. In case of death from a dangerous
communicable disease, the burial or removal must be conducted according to the
rules of the state and local board of health,. _ — /l
Official Title
*Write "Burial" or "Removal' as the use may be Burial Permits must be delivered by the
undertaker to the sexton. Removal "=its must be niveu to the anent of tramportatiao com-
pany. and attached by him to box containing body. Sub•mi,trars will write Sub" before the
words Recutrar of Death.' anal Lice and Embalmer No. below, always siv-
im, numher of license. Fiae or iaaorisoomev[ for reeeiviva a body for burial without Permit.
Name of cemetery Address
This form may be used for disinterment-aeiatamut in aeardsmee with Raalalien 27.