Burial PermitSTATE OF MINNESOTA p Y, �� %S
DEPARTMENT OF HEALTH Burial - Removal - Transit Permit
Section of Vital Statistics Permit No
NAME OFD ED 1 DATE OF DEATH o DEATH COMMUNICABLET
kqe4ilu-I-MJ 9- v^/-I/, 1 ❑ Yeo
AGE LAC DEAr8 (Cia . or T.wuhip) (CO®ty) lJ
5
OF DISPOSAL: PLACE OF D SITION (N116 of <eonotery K —9to17) (City, VDh-go or Towrhi , County, Stop)
CREMATION
El REMOVAL El OTHER (epocH» t.
8= M CLAN OH DUNE DiECTO@ SINE ADD '
♦ our". of Loth h,yloi fBed u repaired by low. per♦ b hereby given to dupe, of this body.
SIGNAT OFRAQATRAE ,(City Mag, or To (Comb' ) 1 D ISS
� ED_
SIGNAT F PERSON IN GR OF C07VEYANCE
AUTHORIZED DISPOSITION A8 STATED 1 ,
SIGNATURE OF 8EZ7lt)�/ OR CEME / e Y O �j DATE RECEl
ABOVE OCCURRED ON:(Dais J , I/
,a ,ea t a 01346