Burial Permit/
Burial - Removal - Transit Permit
NAME OF DECEASED
DATE OF MATH
DEATH COMMUNICABLEf
Kenneth Nor uist
December 5 199
Dye- HG
5 AGE
LACE OF ATH CIfY, vILYOE oR TORNfHIe (COUHTY)
Male 40
Chanhassen, MN Carver
M OD OF D15P05AL.
MLAGE OP "WP SITION (NAME OF CEMETERY OR CN[MATORYI (CITY. VtLL GE ORT %,NEHIP. COYrT. aTATEI
OBURIAL [:] CREMATION
❑REMOVAL❑om,E I„EG,FYI
Chanhassen Cemetery, Chanhassen, Carver, MN
1 NA R OF MOI" FUN R L DIRECTOR
BUSINESS AODRE55 e r t a sFuneral Home
T (7c_
1 200 West Third St., Chaska, MN 55318
certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
R 3 151 cnnr. Vn.ws OR TO Ht' CWNYY TYLE
I
DATE 155UED
Chaska Carver Sub -registrar
12- -94
al NATURE RSON IN H E OF CONVEYANC
AUTHORIZED d5F IT10N 1 RE ETON OR CEMETERY OFFICIAL
DATE RECEIVED
HE -00113-03 (7/84)
This form provided by the Minnesota Department of Hea , Sectio of Vital Statistics Original—Place of Disposition Copy—Sub Registrar