Burial Permit. !F
STATE OF MESOTA
DEPARTMENT OF HEALTH Burial - Removal - Transit Permit
Section of Vital Statistics Permit No. 1366
NAME OF DECRASRD DAB D DEATH COMWUNICABLET
Otto Buschkowaky `-�-�6 1:1 T„ ® N.
SEE AGBPLACR OF DEATH (CI yx01* Ci xfGV= (Cemb)
Malts 87 Litchfield 'Meeker
METHOD OF DISPOSAL:I PLACE OF DISPOSITION (N.e of ..tory er ) (CiWT� or Towpeh(p, Comb. era)
® BURUL ElCSEMITION Chanhassen Twp. Cemetery Chanhassen Car -pr Minn
n REWVAL n OTHER (specify)
OF h
OF
:AL DIBBCIOq BDBDiEBB n n e s B
Daseel, :4lririesotA
Of d.& brag hem Died u teP(rt1 by awe perp aoae, Is hereby ffl m to diepae of Bb bed.
OW. VDlye er Te(gft) (Comb)
DATE ISSUED
n.. 11
SIGNATURE OF PERSOW-IN CMARGR OF CONVEYANCE �1
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE F SJEEXTD OR CEMETERY OFFI I DATE RECEIVED
BD
ABOVE OCCUERON-(D-a) n /f_ n A
6-11-63 7M BK50rder No -85780 v