Burial PermitBurial - Removal - Transit Permit Permit No.
NAME OF DECEASED
DATE OF DEATH
DEATH COMMUNICABLEl
ET
Phillip Roe
Gossard
5-7-1996
1:1 YES NO
SEX
AGE
PLACE OF
DEATH (CITY, VILLAGE OR TOWNSHIP) (COUNTY)
Male
57
Chanhassen, MN. Carver County
METHOD OF DISPOSAL:
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUNTY, STATE)
FRI BURIAL F-1 CREMATION
OTHER (SPECIFY)
F-1 REMOVAL 1:1
Pioneer Cemetery, Chanhassen, MN. Carver Co.
SI:GNATUR F MORTICIAN OR FUN
DIRECTOR
BUSINESS ADDRESS
—0100, 00
loge
520 Second Street, Excelsior, MN. 55331
A certificate of ath ha ' ng been filed as required by law, permission is hereby given to dispose of this body.
NA OFREGISTRAR
CITY, VILLAGE OR TOWNSHIP COUNTY TITLE
DATE ISSUED
;��_ "00//-4�
ExceIsior, MN. Hennepin Co. Sub Registrar
5-8-96
S NATURE OF PEIRSON IN7HAkGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
OCCURRED ON: (DATE)
H E-001 13-03 ( 7/84)
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original—Place of Disposition Copy—Sub Registrar