Burial PermitBurial - Removal -Transit Permit
Permit No.
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Guy Dodge 1
10-21-99
❑ YEN ElNo
X AGE
PLACE OF DEATH (CITY, VILLAGE OR TOWNSHIP
(COUNTY)
M gq
Hennepin
OD OF DISPOSAL:Sarr
LACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY. VILAGE OR TOWNSHIP. CWNTY.STATE)
aBURIAL ❑ CREMATION
❑REMOVAL ❑ OTHER (SPECIFY)
Pioneex Cemetettey
Chanha,"en MN
SIGNATURE M FUNERAL DIRECTOR
BUSINESS ADDRESS
850 E. Main St Anoka,
AW SS303
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
RE OF;=E1 CITY, VILLAGE OR TOWNSHIP COUNTY
TTL6
DATE ISSUED
Anoka Anoka
PAm
Sub. Reg.
10-22-99
ON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIG TORE OF SE CN OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE) /o - . 3 - f y y k
f
d(�c (-C (LlL�--
[o -,R j - /
HE -00113-03 (7/84) 1/iJ
This form provided by the Minnesota Department of Health, ection of Vital Statistics Original—Place of Disposition Copy—Sub Registrar