Burial PermitBurial • Removal • Transit Permit
Permit No.,Y.,Lt 79Y
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLn
Jenner
(Jack) Ernst
July 2, 1989
❑YE/ DNO
AK
PLACEDEATH
CITY, VILLAOE OR TOWN/HIP
iCd1NTY
Male 81 Yrs.
Chanhassen
Carver
O D13 DEAL.
PLACE OF DISPOSITION INAM3 OF CEMETERY OR CREMATORY (CITY.
VILLAGE OR TO IRUPOP, COYIRY,/TIRE
BURIAL ❑ CREMATION
❑ REMOVAL ❑O ER (SPECIFY)
Chanhassen Cemetery
Chanhassen, Minn.
SIR OF MORTICIAN OR FUNERAL DIRECTOR
BUSINESS ACDRE5 s
"
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.
1 AR
ICITY, VIWGE OR TOWNSHIP (CWRTY) [nT ,:
DATE (SSU CID—
DExcelsior
ExcelsiorHennepin Sub -Reg.
1=x 7-6-19
S R E ON IN HAR E OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE)
HE -00113-03 (7/64)
This form provided by the Minnesota Department of Health, Section of Vital IS Original—Place of Disposition Copy—Sub Registrar