Disposition Permit28 2017 09,592`1 Henry W. AoefSon 6127293634
page 1
DISPOSITION PERMIT
DECEDENT'S NAME
DAVID HAROLD KELM
GENDER
MALE
DATE OF BIRTH /AGE
05/30/1927 / 90
DATE OF DEATH
12/24/2017
AUGUSTANA HEALTH CARE CTR -APPLE VALLEY
PLACE OF DEATH
14650 GARRETT AVENUE
APPLE VALLEY, DAKOTA, MINNESOTA
FUNERAL DIRECTOR
GRANT D KUHLMANN M4003
HENRY W. ANDERSON MORTUARY I LIC # 0122
FUNERAL HOME OR
3640 23RD AVENUE SOUTH
OTHER ENTITY
MINNEAPOLIS MINNESOTA
PLACE OF DISPOSITION
CEMETERY
PIONEER CEMETERY
CHANHASSEN CARVER MINNESOTA
According to Minnesota Statutes, section 149A.93, subdivision 3,
section 144.221, and Minnesota Rules, part 4601.1500, the fact of
death has been filed with the Office of Vital Records,
Molly Mulcahy Crawford
STATE REGISTRAR
DISPQSITION PERMIT ISSUE DATE 12/28/2017 08:54 AM
(SIGN URE -OF FINAL D POSITION FACILITY OFFICIAL)
(PRINT NAME OF FINAL DISPOSITION FACILITY OFFICIAL)
Rev 12/2013