Burial Permitl
Burial - Removal - Transit Pemlit
1 • 1 1 /
NAME OF DECEASED
OATE OF DFATH
DEATH COMMUNICABLE?
Jack -Wayne Robinson
pril 5, 2004
❑"■'
Q NO
SEX AGE
PUCE OF DFATH IOTI'.VLLlAOEw TOMMM
ACE
WOMn'�
Male 52
Hennepin
METHOD OF DISPOSAL
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CRY, VILLAGE OR TOWNSHIP, COUNTY, STATE)
MBURIAL ❑CREMATION
Chanhassen Pioneer Cemetery
I
EF-1 OT
Chanhassen, Carver ,MN
E OF MORTIC
OR FUN DIRECTS*
BUSINESS ADDRESS
i
16394 Glory Lane Eden Prairie
MN 55344-
A certi 1 o
h having
h d as required by law, pennission is hereby given to dispose of this body.
E OF R IS
` (
IMTY, WL M Tams ) Mc11IMm
RRLE)
DATE ISSUED
�j.
Prairie Hennepin
Sub -Registrar
4/6/2004
SIG TORE OF PEFOW0.4cHxROE
OF CONVEY
AUTHORED DISPOSITION
RE OF ETERY OFFIC
DATE RECEIVED
AS STATED ABOVE
A r 91 2004
OCCURRED ON 313ATE1
P
KE -00113-03 (7184) ILJ
Original—Placed DiEpoEalon Copy—Sub Regisiral