Burial PermitSTATE OF MINNESOTA p oCa (oS L
DEPARTMENT OF HEALTH Burial - Removal -Transit Permit
Section of Vital Statistics Permit No 825
NAME OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
kargaret S. Roers I Kay 14, 1974 Too ❑X No
SEX AGE PLACE OF DEATH (Chy Village or Toersehlp) (Comb)
Female 91 Years I Waconia Carver
METHOD OF DISPOSAL: I PLACE OF DISPOSITION (Nemo of esoty or r tq) (tatty, ripeso or Teripeetp. I:euq, howl
BURIAL El CREMATION
Chanhassen Cemetery Carver Ctp, Minn.
REMOVAL OTHER (Specify)
of
1 OR FUNERAL DIRECTOR BUSINESS ADDRESS
--lti 520 -2nd. St., Excelsior, Minn.
A eordDeaw of deed, banes her- filed r reedtod by leer, peredwbp b hereby sirs or dbyeoo of " body.
(y (City. Vmoso or Tower►y) (Cooty)
—4- 1 Excel for Hennepin
r CHARGE OF CONVEYANCE
DATE ISSUED
5-17-1974
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON 0M*CORTERT OFFICIAL I DATE RECEIVED
ABOVE OCCURRED ON- (Dal.