Burial PermitSTATE OF MINNESOTA Burial
Q
DEPARTMENT OF HEALTH Bur - Remora! - Transit Permit a 6s
Section of Vital Statistics Permit No
NAME OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
Mrs. J: oe rine Buschlowsk 4— I El Y" ®N.
8Ei ACE PLACE OF DEATH (Cib VpiFiE"10W0M (Comb)
Female I 85 Litchfield Meeker
METHOD OF DISPOSAL: PLACE OF DISPOSITION (No d avot.q or7Ed6plNW (CMX3MW [— T—whip. Comb, Stool
® BURIAL CREMATION
REMOVAL OTHER (.oeeNT) Chanhassen Cemete:Rr Chanhassen Carver Yinno
SI ATURR OF i OR Al. DIRECTOR BUSHIRS6 ADDRESS
1� ,' � � D,,Issel, Mimes--ts
Iq /A MMI. to of Mtb 6aHm brm DId u r .Id by t.-. Forsloot.e Y bw&y fhm to dio d riio boy.
� c'RTRAR /j ��� (��.7(YBIKa or lFw' (Comb) DISSUED
SI 7/74,07,
i/i_�c� c/�.r/%-�:-i/ Dasael Meeker 14— 4— 5-86
AUTHORIZED DISPOSITION AS STATED SIGNATURE OF SEXTON OR CEIUMBEY 9FFICIAL DATE RECEIVED
ABOVE OCCURRED ON: (Dot.) ! ° I
i-(
6-11-63 2M BKS Order No.85280 Q