Burial Permit,;I -t~ -%q•J Burial - Removal - Transit Permit Permit No.
NAME OFD CEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Harriet L. Kurtz
Mav 13, 1987
❑YES ][][NO
SEX AGE
PLACE OF Di (CITY, "LLAGE OR TOWrESNIP)
(COUNTY)
Female 48 Yrs.
St. Louis Park
Hennepin
METHOD OF DISPOSAL.
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUNTY,STATE)
® BURIAL ❑ CREMATION
aREMOVAL ❑
Chanhassen Cemetery
Chanhassen, Mn.
OTHER (SPECIFY)
N RE OF MORTICIAN OR FUNERAL DIRECTTMT
BUSINESS ADDRESS
520 -2nd. Et., Excelsior, Mo.
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
NA R OF REGISTRAR CITY, VILLAGE OR TOWNSHIP) CWNfY
prYi_E-T
DATE ISSUED
Excelsior Hennepin
Sub -Reg.
5-15-1987
5 A F PERSON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE)
H E-00113-03 (7/34)
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar