Paul J KroghU\
USE BLACK INK ONLY - MAKE NO ERASURES,
OR OTHER ALTERATIONS
1A. NAME OF DECEDENT -FIRST (GIVEN) 16. MIDDLE1C. LAST (FAMILY) I II;?
2. DATE OF BIRTH
3. DATE OF DEATH
4. SEX
PAUL J.
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MONTIJ,
1H 3%�00
MALE
5A. CITY OF DEATH I5B. COUNTY OF DEATH - OUTSIDE CALIF.,
6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
ENTER STATE
OF INFORMANT
LOS ANGELES LOS ANGELES
ROBERT KROGH, FATHER
1103 SOUTH 13TH STREET
7A. TYPED NAME AND ADDRESS OF CALIFORNIA - FUNERAL DIRECTOR OR PERSON ACTING AS SUCH ; 7B. CALIF. LICENSE NUMBER
GARDENSIDE FUNERAL SERVICE -IFAPPLICABLE
13450 PARAMOUNT BLVD.
BLAIR, NE 68008
SOUTH GATE, CA 90280-8251 FD -1-557
8A. SIGf 4TURE OFAPPLICAN Per ogtakingpetmit,6B. DATE SIGNED
g' = .._^- q 11,7
I hereby acknowledge as. applicant that the proposed disposition stated herein is one of the dispositions authorized by Section 103055
ACKNOWLEDGEMENT
OF APPLICANT of the Health and Safety Code, and was authorized pursuant to Section 7100 of the Health and Safety Code.
J ,:�
PERMIT
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF
THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE AUTHOR -AUTHORIZATION
9A. AMOUNT OF FEE PAID ��DATE PRfV11T I UED 9C. SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
OF
ITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT.13.OO
NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA
l/17/2003 po. 061-4620
LOCAL REGISTRAR
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH - 9E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION -
ANY CHANGE IN DISPOSI-
IF DEATH OCCURRED IN CALIFORNIA IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
TION EQUIRES ANEW
PERMIT To SHOW FINAL
313 N. FIGUEROA STREET, ROOM L-1
DISPOSITION
LOS ANGELES, CA 90012
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE ITEMS FOR CORONOR'S USE ONLY
FIA. BURIAL (INCLUDES ENTOMBMENT) FIE, TEMPORARY ENVAULTMENT I. DISPOSITION PENDING - REMAINS LOCATED AT
ME. CREMATION FIR DISINTERMENT (Name and Address)
C. DISPOSITION OF CREMATED REMAINS OTHER FIG. SHIP IN TO CALIFORNIA
THAN IN A CEMETERY
FID. SCIENTIFIC USE - -- - I D. TRANSIT TO OUTSIDE OF CALIFORNIA
11 A. NAME AND ADDRESS OF CALIFORNIA CEMETERY ;11 B. DATE BURIED 11C. SIGNATURE OF PERSON IN CHARGE OF BURIAL
BURIAL
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY 11267111� TE CREMATED; 12C. SIGNATURE OF PERSON IN CHARGE OF CREMATION
F CREMATION
ROOSEVELT MEMORIAL PARK CREMATORY
18255 S. VERMONT AVENUE ��/1sf,7
m
1y r
GARDENA, CA -90248
v
J
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 113B. DATE RECEIVED 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
a SCIENTIFIC
2 USE
_
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE ;14B. DATE SHIPPED 14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED OF PLACING WITH THE CARRIER
TRANSIT
CAMPBELL-AMAN FUNERAL HOME
o
444 S. 17TH STREET BLAIR NE 68008
15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION ;15B. DATE OF 15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER OF
SCATTERING/BURIAL
SUFFICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION.; DISPOSITION CHARGE OF DISPOSITION CREMATED REMAINS DIS -
AT SEA OR
IF BURIAL AT SEA, ONLY ENTER LATITUDE AND LONGITUDE I POSER - IF APPLICABLE
DISPOSITION OTHER
THAN INA CEMETERY
-
COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION. THE PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE
FOR COMPLETING AND FORWARDING THE PERMIT WITHIN 10 DAYS OF DISPOSITION TO THE REGISTRAR OF THE DISTRICT IN WHICH DISPOSITION OCCURRED
OR THE DISTRICT NEAREST THE POINT WHERE THE CREMATED REMAINS WERE SCATTERED AT SEA. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL
OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE.
COPY 1 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS9 (REV. 3/03)