Walter C. Wagner Burial permitBurial -Removal -Transit Permit
Permit No.
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NAMEO D AS D
DATE OF DEATH
DEATH COMMUNICABLE?
WALTER C. WAGNER
February 22, 1998
�YEs �No
--.
S A
AGE
PLACE OF DEATH CITY, VILLAGE OR TOWNSHIP) (COUNTY)
Male
1 88
Shakopee
Friendship Manor Nursing Home Scott
METHOD OF DISPOSAL:
PLACE OF DISPOSITION )NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUNTY,STATE)
® BURIAL ❑ CREMATION
Pioneer Cemetery
❑ REMOVAL ❑ OTHER (SPECIFY)
Chanhassen, Minnesota Carver County
SIGNATURE OF M RTICIAN OR FUN
ECTOR
BUSINESS ADDRESS
6527 Portland Ave., Richfield, Minnesota 55423
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SIGNATURE OF R GISTRAR
(CITY, VILLAGE OR TOWNSHIP(COUNTY) TITLE
DATE ISSUED
Richfield Hennepin sub reg
2/26/98
SIGNATURE F PERSON IN'CHAIRGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIG NA RE OF SEXT9N0DR CEMETERY OFFICIAL
DATE RECEIVED
AS STATED ABOVE
_
G
A —,A �7
OCCURRED ON: (DATE)
�
HE-00113-03 (7/84) 4-,'
This form provided by the Minnesota Department of Health, Secti of Vita Statistics Original —Place of Disposition Copy —Sub Registrar
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