Burial PermitBurial. Removal • Transit Permit
Permit No.
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
BABY BOY, EVAN VICTOR DOYLE
7-8-2005
1:1YEa ®No
SEX AGE PLACE OF DEATH (CITY, VILLAGE OR TO"WHIP) (COUNTY
male ---- Edina, mH_ Hennepin Co.
METHOD OF DISPOSAL:
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY( (CITY, VIULAOK OR �HIP. CWNTV.fTATt(
® BURIAL CREMATON
❑ REMOVAL ❑ OTHER (SPECIFY)
Pioneer Cemetery, Chanhaagen, M. Carver Co.
i A R MORT1CIAN OR FU AL DIRECTOR
BUSINESS ADDRESS
..i
16394 Glory Lane, Eden Prairie, M. 55344
A certificate of death ha ' g been filed as required by law, permission is hereby given to dispose of this body.
51 .x AR CITY. VILLAGE OR Towne P fcouivi (177,K)Di
ISSUED
Prairie, M. Hennepin Co. Sub Registrar
I7
7-11-2005
i NA RE OF PERSON CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (OATS)
HE -00113-03 (7/54)
This form provided by the Minnesota Department of Health. Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar