Burial PermitBurial - Removal - Transit Permit
Permit No.
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Gene B. Wyatt
October 4, 2002
E]YES ZINO
SEX
AGE
PLACE OF DEATH (CITY, VILLAGE, OR TOWNSHIP) (COUNTY)
Male
68
Eden Prairie Hennepin
METHOD OF DISPOSAL:
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CRY, VILLAGE OR TOWNSHIP, COUNTY, STATE)
BURIAL CREMATION
Chanhassen Pioneer Cemetery Chanhassen
REMOVAL OTHER (SPECIFY)
Hennepin Minnesota
SIGNAnIR RT��NN O FUNERAL DIRECTOR
BUSINESS ADDRESS
ap
cY(j i� ,»-*��
Albin Chapel, 6855 Rowland Road., Eden Prairie, MN 55344
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SIG R S (CRY, VLAGE OR TOWNSHIP (COUNTY) (TRE)
A�E
Zril� Minneapolis,Hennepin Sub -Registrar
7IS-S2UoED
oZ -
SIGNATURE OF PERSON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIG
A URE OF S CEMETERY O ILIAL
DATE RE CENED
AS STATED ABOVE
OCCURRED ON: (DATE)
HE -00113-03 (7194) v
This form provided by the Minnesota Department of Health, SedQn Ital Statistics Original —Place of Disposition Copy —Sub Registrar