Julia Lavina BendorfAPPLICATION AND PERMIT O. DISPOSITION
USE BLACK INK ONLY—MAKE NO ERASURES, WHITEOUTS OR Ol
1A. NAME OF DECEDENT—FIRST (GIVEN) 11B. MIDDLE 11C; LAST (FAMILY)
-7111 TA I I A111`11A I nrmnnpF
5A. CITY OF DEATH 5B. COUNTY OF DEATH --OUTSIDE CALIF.,
Eureka i ENTER,a 6o yl Tlt
7A. TYPED NAME AND ADDRESS OF CALIFORNIA --FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 7B. CALIF. LICENSE NUMBER
Pierce Chapel I —IF APPLICABLE
707 H St., Eureka, CA 95502-008 FD -198
ACKNOWLEDGMENT OF APPLICANT I hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized by
Section 10376 of the Health and SafeU Code and was authorized Pursuant to Section 7100 of the Health and Safe Code.
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI- 9A. AMOUNT OF FEE PAID 9B. DATE PERMIT
PERMIT SONS OF THE CALIFORNIA HEALTH AND SAFETY CODE
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED :Dec. 23 8
AUTHORIZATION OF IN THIS PERMIT.
LOCAL REGISTRAR NOTE: THIS PERA9T GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA. 7.00
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH-- 19E. ADDRESS OF REGISTRAR
ANY CHANGE IN DISPOSI IF DEATH OCCURRED IN CALIFORNIA I IF DISPOSITION IS TO OCCU
TION REQUIRES A NEW
PERMIT TO SHOW FINAL
DISPOSITION. 529 11
10 St., Eureka, CA
95501
I
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE ITEMS
A. BURIAL (INCLUDES ENTOMBMENT) E. TEMPORARY ENVAULTMENT
Q B. CREMATION F] F. DISINTERMENT
C. DISPOSITION OF CREMATED REMAINS OTHER FIG. SHIP IN TO CALIFORNIA
THAN IN A CEMETERY
D. SCIENTIFIC USE H. TRANSIT TO OUTSIDE OF CALIFORNIA
1AyNAN1E AND ADDRESS OF CALIFORNIA CEMETERY 1118. DATE BURIE(
BURIAL I a� r ce try I
Blair, NB Washington County
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY 12B. DATE CREMAT
w
w
U
CL
a
w
5-
2
0
U
I
CREMATION I
N/A
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 113B. DATE RECEh
SCIENTIFIC
USE Pi
i /A I
I
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE 1148. DATE SHIPPE
TRANSIT iV�rSO}1CTD REtv)AINS A jQ SHIPPED
74th Clay G s., Fort Calhoun, NB
SCATTERING AT SEA 15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUF- 15B. DATE OF
OR �F1CIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION DISPOSITION
DISPOSITION OTHER J
HAN IN A CEMETERY
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY, CREMATORY, FACILIT
CHARGE OF DISPOSING OF THE CREMATED REMAINS.
�' COPY 2 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF E
CERTIFICATE OF DEATH
STATE OF CALIFORNIA
STATE FILE NUMBER USE BLACK INK ONLY
IA. NAME OF DECEDENT—FIRST B. MIDDLE IC. LAST (FAMILY)
(GIVEN) i LAV INA BEN
JULIA S. DATE OF BIRTH—MO,
4. RACE S. HISPANIC—SPECIFY
White YES NO March 1 189
JOB. STATE OF
DECEDENT 8. STATE OF 9. CITIZEN OF WHAT IOA. FULL NAME OF FATHER I BIRTH
PERSONAL BIRTH COUNTRY
DATA B Nelson Jackson I Sweden
14. MARITAL STATUS
12, MILITARY SERVICE 13. SOCIAL SECURITY NO.
I!
19 _ TO 19_U NONE 505-72-8735 W
ISA. USUAL OCCUPATION 1180 USUAL KINDOFBUSINESS ) ISC. USUAL EMPLOYER
OR INDUSTRY
omemaker ) '
ISA. RESIDENCE—STREET AND NUMBER OR LOCATION
USUAL
DUE TO lcl
RELATED TO CAUSE GIVEN IN 21
25. OTH�I`FICANCONDITIONS CONTRIBUTING Tt1l
-
NUMBER 18F. STATE OR FOREIGN COU
RESIDENCE
IED. COUNTY
(IBE.
NTY
I IN COU1
CA
Humboldt
16YEARS
16
I CERTIFY THAT TO THE BEST OF MY KNOWLEDG DEAD O PEE OR TITLE OP CPHYSI-
IDA. PLACE OF DEATH
118B. IFONEN P rTAL
PER/OPP D A 1
1 BC. COUNTY
PLACE
Family Affair Guest Hare
' ---
' Humboldt
OF19D.
STREET ADORESS—STREET AND NUMBER
121,
OR LOCATION (19E. CITY
DEATH
STATED.
0.
Eureka
28. MANNER OF DEATH—SpeCIIY one: natural, accident,
744 Stewart
suicide, )amicide, pending investigation or could not be determined
DEATH WAS CAUSED BY/:'� (ENTER ONE CAUSE PER LINE FOR
A. B. AND C)
�ON,,L^Y
IMMEDIATE (A)' /jtA (,�,D1 V'r Cc
iii
`'SL�'Q��C,
34A. DISPOSITIONS) C,F�O�eNI.nA�QISSPOS,ITION—NAME AND ADDRESS i 34C. DATE MO,
CAUSE —
13VI"A fr- l• Y
DIRECTOR
CAUSE
OF
%1
K
SC VD
C�
DEATH
IB) jiQ Y
DUE TO
A. B, C. D, E.
STATE
VS -1 l (REV. J -a Ll
'ERTIFICATION This is to certify that the above is a true e
DUE TO lcl
RELATED TO CAUSE GIVEN IN 21
25. OTH�I`FICANCONDITIONS CONTRIBUTING Tt1l
28
I CERTIFY THAT TO THE BEST OF MY KNOWLEDG DEAD O PEE OR TITLE OP CPHYSI-
OCCURRED AT THE HOUR, DATE AND PLACE STATED FCAUSES
STATED.CIAN'S 27A, DECEDENT ATTENDED SINCE( DECEDENT LAST SECERTIFICA-
E ATTENDING PHYSICIAN'S NANTION
MONTH. DAY, YEAR MONTH. DAY, Y
-_ a_'.�_k IJ. Irvine, MD 22
I CERTIFY THAT IN MY OPINION DEATH OCCURRED AT
28A. SIGNATURH AND TITLE OF CORONER OR
THE HOUR, DATE AND PLACE STATED FROM THE CAUSES
STATED.
0.
CORONER'S
28. MANNER OF DEATH—SpeCIIY one: natural, accident,
30A. PLACE OF INJURY
suicide, )amicide, pending investigation or could not be determined
USE
ONLY
32. LOCATION (STREET AND NUMBER OR LOCATION AND CITY) 33. DESCRIBE H
34A. DISPOSITIONS) C,F�O�eNI.nA�QISSPOS,ITION—NAME AND ADDRESS i 34C. DATE MO,
FUNERAL
13VI"A fr- l• Y
DIRECTOR
TR/BU 1 Rlair
AND
R151
38A. NAME OF FUNERAL DIRECTOR IOR PERSON ACTING AS SUCH) 138�8.�LICE SE NO. gena" TVnn'LOCALREGISTRAR
pierce Cha el ; -198 ►By'
A. B, C. D, E.
STATE
REGISTRAR
...,.v ...n--l—S. WHITEOUTS. OR OTHER ALTERA'
VS -1 l (REV. J -a Ll
'ERTIFICATION This is to certify that the above is a true e