Burial PermitBurial • Removal - Transit Permit
Permit No. 76
NAME OF DECED
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DATE OF EATH
OEATH COI IMUNICABr.Et
,� ea 74? r7
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9j���1�r99
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AGE
PLACE CIF ATN (CIIW. VI Dr: OR WHIP
ICWNTY
OF DI$ OSgL
RIAL ❑ CREMATION�y-�PC
PLA OpF DISPc/e:ITON INAME OP�C)��IIWTe:RY OR
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CAKINA`T.ORY If,I,TY. VILLADI oR TO�x�a/M�I,P/r C�jWIRYi smarE)
1.. �/y,.,�Y( LCf�r,� A'•i/L/
❑ REMOVAL ❑ OTHER (aPtC.")
J
3111044�RK O AN OR
BUS S ADORES$
`d 50 27�✓j<.n ��'u
t 0 pct /�iLl
A certificate of deat-h-1-am-olmn filed as required by law, permission is hereby given to dispose of this body.
R
CI VIuwOE OR TOWNSHIP (Cjuinrvl
thmnLal
DATE I SU D
!
R O E ONVEVgNCE
AUIHORIZED DISPOSITION
AS SrATED ABOVE
51
RE XTON CEMETERY OFFICI
A I
DATE RECEIVED
II)q-
OCCURRED ON: IDme) oy. '1Sr
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HE-00113-03 Main / r
This form provided by the Minnesota Department o Health, Se of Vital Statistics Original—Place of Disposition Copy—Sub Registrar