Disposition PermitBurial - Removal - Transit Permit
Permit N .
t -t G/v. 5
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Nellie A. Anderson
I Oct. 26, 1986
❑Ysas ®NO
SEX AGE
PLACE OF DEA (CITY. VILLAGE OR TOWNSHIP
ICWNTY)
Female 92 Yrs.
I Excelsior
Hennepin
METHOD OF DISPOSAL:
PLACE OF-DISPOSInON (NAME OF CEMETERY OR CREMATORY) (CITY, VIWGE OR TOWNSHIP. COUNTY.STATE)
BURIAL ❑CREMATION
Chanhassen,Cemetery
Chanhassen, Mn.
❑REMOVAL ❑OTHER(SPECIFY)
OF MORTICIAN OR FUNERAL DIRECTOR
BUSINESS ADDRESS
MSIRE
T.
520 -2nd. St., Excelsior Mn.
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
TORE Or REGISTRAR CITY. VILLAGE OR TOWNSHIP COUNTY
(TITLE
DATE ISSUED
Excelsior Hennepin
Sub -Reg.
0-28-1986
ATVRE OF PERSON IN CHARGE OF CONVEYANCE
AVTMORIZED OISPOGIIIOM
SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE)
HE -00113-03 (7184)
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar