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Burial Permit
Burial -Removal-Transit Permit Permit No. cT � 5-. 1 E OF DECEASED DATE OF DEATH Oli C01MIAUNICABLET Viola Wilhelmine Amalia Roers April 10, 1994 ❑YES ®NO SEX AGE PLACE OF DEATH (CITY, VILLAGE OR TORNSHIPI iCWHTY) Female 87 Shakopee, MN Scott METHOD OF DISPOSAL: PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) ICITY, VILLAGE OR TOYMSHIP, CWNTY,STATEI ©BURIAL F_] CREMATION Chanhassen Cemetery, Chanhassen, Carver, MN ❑ REMOVAL ❑ OTHER (SPECIFY) SIG NA R OF MOR FU RAL DIRECTR O CIA 14 � /f BUSINESS ADDRESS Bertas Funeral Home -1 f`' 200 West Third St., Chaska MN 55318 A certificate of death having been filed as required by law, permission is hereby given to dispose of this body. SIGNA E OF REGI_ AR% j I CITY, VILLAGE OR TOWNSHIP CWMY) (nYIUsj DATE ISSUED Y!�/� <_ Chaska Carver Sub -registrar 4-12-94 SI OF Pi,RSON IN CHARGE OF CONVEYANCE AUTHORIZED DISPOSITION SIGNATURE OF SEXTON OR CEMETERY OFFICIAL DATE RECEIVED AS STATEO ABOVE OCCURRED ON: (DATE) HE -00113-03 (7/84) This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar