Burial PermitII
Burial - Removal - TTansil Permit PerrrW �. 12052004
Christopher
Thomas Young
December 5, 2004
07Sf❑ No
SEX AGE
PLACE OF DEATH ICO'. YAUOE OR TOPOOMM (Co1MM
Male 1 Day
Shakopee
Scott
METHOD OF DISPOSLL
PLACE OF p3POSrTIOM (NAME OF CEMETERY OR CREMATORY) (CITY. VILLAGE OR TONM.SMIP. COUNTY. STATE)
MBURIAL ❑CREMATION
Chanhassen Pioneer Cemetery
❑ R9WAL
aFErsn Burial
Chanhassen, Carver ,MN
RE MORTICIAN
OR FUNERAL DIRECTOR
BUSINESS ADDRESS
16394 Glory Lane Eden Prairie MN 55344-
A c
avin n filed as required by law, perfnission is hereby given to dispose of this body.
RE REG
Icrt VLL"M OR Ton"Nl1 (COUNTY) ITRLE)
DAT E ISSUED
Eden Prairie Hennepin Sub -Registrar
iz/o�/zoo
SIGNATURE
of
AUTHOR® DISPOSmON
SIGNATURE OF SEXTON OR C 31ETEiY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
Dec 9, 2004
OCCURRED OWPATE)
nerAlT T,ws jf2 )
Original—Place or Disposition copy—Sub RMgishal