Burial Permit7
STATE OF MINNESOTA
DEPARTMENT OF HEALTH Burial- Removal -Transit Permit
Section of Vital Statistics Registration Permit No
NAYS OF DECEASED DATE OF DBATR DEATH COMMUNICABLET
Floyd J. Roers ,�iugust 7, 1981 I T. El
Na
SEX AGE PLACE OF DEATH (CIb Vdhe w Twwn") (Caub)
Male I 77 Minneapolis Hennepin
METHOD OF DISPOSAL: PLACE OF DISPOSITION (liar eI eaeNrT er ereaulM) (C14. V111m. K Te-e,MF. Ceeey. Sla/e)
® BURIAL ❑ CBEYATIONI Chanhassen Cemetery
El REMOVAL El OTHER (aeed4) Chanhassen, MN 55317
1 SIGNATURE OF MORTICIAN OR PYNERAL DIRECTOR BUSINESS ADDRESS
A artlDpb of 4atb ba"aff Mee DIN u ,palm bT la-. pemb-Iee Y bent' d•ee Te d:aeeee et TMa bey.
61GNAOP REGISTRAR (Chr. Vfll T ar Ta-Wle) (Caaeb) DATE ISSUED
Chaska Carver ug.10,1 81
CHARGE OF CONVETANCE
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL I ---- ------
ABOVE OCCURRED ON:(DaM)