Burial Permitp 4A -7!;'-. . 3
DEPARTMENT OF HESTATE OF ALTH Burial - Removal -Transit Permit
Section of Vital Statistics Permit No
NAME OF DECEASED DATE OF DEATH DEATH COMMUNICABLE?
Alice Roers I Feb. 23, 1965 O Yeo 7R N.
SEX AGE PLACE OF DEATH (City VIWn or Town") (Comb)
Female 86 Chaska, Minn.
METHOD OF DISPOSAL: PLACE OF DISPOSITION (Nor of erofa or emote ) (City. VH1aF. or To" WF. Comty. State)
BgM(AL CREMATION Chanhassen Cemeterq Chanhassen Twp., Carver Cc
REMOVAL OTHER (oMe)ty) Minn.
SI NAT F MOH (IAN OR PUN MWTOR BUSINESS ADDRESS
"haska, Minn.
A a ted death baring been filed u required by law, Forr.1�M& 4 bereb? Floe& W dioFaw, of this bad?.
SIGNATURE OF BE TRAM � (City. VIRwo or T-w&-biF) (Comb) DATE UED
A n Chaska. Minn. eb. 2�V1 19 65
RIGID&URE OF Psar IN CHARGEOF
CONVEYANCE
AUTHORIZED DISPOSITION AS STATED
ABOVE OCCURRED ON: (Date)
SIGNATYRE
I
OF SEXTOI'A OR CBNqqI'S6Y OFFICIAL
/ -1L ;17, t h/ — ,A
DATE RECEIVED
as//. Le
6-II-63 MI BKSOrd.r No.85980