Burial PermitBurial - Removal - Transit Permit Permit No.
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Robert Charles Hayes
February 17, 2000
❑Ys X❑ W
SEI[ AGE
PLACEOFDEATH (Co Y,MLLAGEOa TOWNSH1M (COUNTY)
Male 1 61
Chanhassen Carver
METHOD OF DISPOSAL
PLACE OF DSPOSn10N (NAME OF CEMETERY OR CREMATORY) (Cr , VNLAGE OR TOWNSHIP, COUNTY, STATE)
MBURIAL ❑CREMATION
Pioneer Cemetery
F1 REMOVAL ❑OTHER(sPECIPn
Chanhassen, Carver ,MN
SIG RE MORTICIAN UN
BUSINESS ADDRESS
520 Second Street Excelsior MN 55331-
cate of death having been filed as required by law, permission is hereby given to dispose of this body.
F REG (cITY,MLUDEoeTOWNSHIP) (cWNT1) DOLE)
51ATIRE
GATE ISSUED
F PERSOIM CHARGE OF CONVEYANCE
AUTHOR D DISPOSI IONSIGNATURE
OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE Feb 22, 2000
OCCURRED ON :(DATE)
HE 00113-03 (7/84)
Original—Place of Disposition Copy—SOD Regl$r1al