Burial PermitSTATE OF MINNESOTA
DEPARTMENT OF HEALTH Burial - Removal - Transit Permit
Section of Vital Statistics
NAME OF DECEASED
SRX AGE
/V 163
METHOD OF DISPOSALt
BURIAL CREMATION
® REMOVAL OTHER UpoeHy)
SIGNATU$E•0R,#ORTICIAN OR FUNERAL DIRECTOR
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448'
Permit No
DATE OF DEATH DEATH COMMUNICABLE?
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PLACE OF DEATH (City VlDapo or T ----hip) (Comb)
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PLACE OF DISPOSITION ( oma of woaotvr Of ."mato") (City. VWmo or Township, Cooay, Stat.)
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z ;BUSINESS ADDRESS
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A aortifirato of death bvipp., offal by law, pormWion Is hereby dyon to di pose of this body.
SIGNATURE OF 8ECI8 • • o yraToweahlD) (CANptri P N I DAT�I881j�� 1g
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SIGNATURE OF PERSON IN
AUTHORIZED DISPOSITION AS STATEDI SIGNATURE OF SEXTON OR CEMETERY OFFICIAL I DATE EBUBIVED
ABOVE OCCURRED ON: (Date)
10-18-66 rM BKS ORDER NO. 91346
-411WR