Burial PermitBurial - Removal - Transit Permit -77- Permit
NAME OF DECEASED
DATE OF DEATH
DEATH COF9AUNIGBLET
Stanley A. 11' 1 Nickle
June
SEX
AGE I PLACE OF DEATH CITY, VILLAGE OR TOINNINIP( fCdINTY(
ale
70 Yrs.1 Waconia Carver
METHOD OF DISPOSAL:
PLACE OF dSP081TOH [NAME OF CEMETERY OR CREMATORY( (CITY. vaLL GE OR TOWTANIPo OOJ Y. SWURK)
BURIAL F-1CREMATION
❑ REMOVAL ❑ O"IER (SPECIFY[
Chanhassen Cemetery Carver Cty. Minn.
TURE OF MORTICIAN OR FUNERAL DIRECTOIT
BUSINESS ADDRESS
520 -2nd. St., Excelsior Mn.
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
5 TURF OF REGISTRAR CITY. vILLAGE OR TOWNSHIP ICOUNTY ("nrLel DATE ISSUED
Excelsior Hennepin Sub -Reg. -5-1984
GNATURE OF PERSON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE[
This fIN2
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Registrar