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APPLICATION AND PERMIT FOR DISPOSITION
USE BLACK INK ONLY—MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS
(GIVEN) I 1B. MIDDLE - 1C. LAST (FAMILY)
I 2. DATE OF BIRTH 3. DATE OF DEATH 4. SEX
15B. COUNTY OF DEATH—OUTSIDE CALIF., 6, NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
ENTM ST T OF INF MANT
� E -mento ETV eVe Krol " _ 'Z4_'
cu ivAMr AND AUUHESS OF CALIFORNIA—FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 78. CALIF. LICENSE NUMBER �°y �3.
I �.3�,a�} wOC}walA„ T".iC%.°sF
24CR=lt �r errion Mortuary ea:�'*ay I —IF APPLICABLE Citrus Ca tt^g _
T aneoaks,95628 1-11 4 8A SIGNATURE OF APPLICANT—Person taking permit) 8B. DATE SIGNED
ACKNOWLEDGMENT OF APPLICANT I hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized by ? ,a p
Section III10376 oflia. the Health and Sate Code and was authorized ursuant to Section 7100 of the Health and Sate Code. _1� ; t �` IfC'
PERMIT THIS PERMIT IS ISSUED IN ACCORDANCE WITH PRO"
9A. AMOUNT OF FEE PAID 9B. DATE PERMIT ISSUED 19C. SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODE 1
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED I� `aC:1.SC'4,yi I
AUTHORIZATION OF IN THIS PERMIT. e �e
LOCAL REGISTRAR NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA. I QGd 7/199 � I Fax tj
ANY CHANGE IN DISPOSI 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH— 19E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION—
TION REQUIRES A NEW IF DEATH OCCURRED IN CALIFORNIA I IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
PERMIT TO SHOW FINAL 3701 5Ai"C'3,nch Center Poad I
DISPOSITION. I
a €A ie i E3 1—ca 3ti2 1
10. AUTHORIZED DISPOSITIONS) CHECK APPLICABLE ITEMS
FIA. BURIAL (INCLUDES ENTOMBMENT) E. TEMPORARY ENVAULTMENT
B. CREMATION F. DISINTERMENT
C- DISPOSITION OF CREMATED REMAINS OTHER
THAN IN A CEMETERY G. SHIP IN TO CALIFORNIA
D. SCIENTIFIC USE H. TRANSIT TO OUTSIDE OF CALIFORNIA
11A. NAME AND ADDRESS OF CALIFORNIA CE—
FOR CORONER'S USE ONLY
E1. DISPOSITION PENDING—REMAINS LOCATED AT
(Name and Address)
ERY
BURIAL 1 11 B. DATE BURIED 111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL
I _ I
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
°J �9 I 12B. D ECR ATEDtI 1 C. S19NATUR F PE ON IN HARGE OF MATI
CREMATION M
73A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAIN 138. DATE RECEIVEDI 13C. SIGNATURE OF PERSON IN CHARGE F CILIT
a SCIENTIFIC
USE
I
w 14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHE E
Lu Ml
OR CREMpTED REMAINS ARE TO BE SHIPPED I 14B. DATE SHIPPED I 14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
TRANSIT al % s ai i V I I OF PLACING WITH THE CARRIER
0 213 So j 16, Ate t Blair, xis
I
SCATTERING AT SEA
15A. ADDRESS, NEAREST POINT O SHORELINE OR OTHER DESCRIPTION SUF- 115B. DATE OF IC. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER
DISPOSITION OTHER
OR FICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION DISPOSITION CHARGE OF DISPOSITION I OF CREMATED RE-
HAN IN A CEMETERY I MAINS DISPOSER
—IF APPLICABLE
I I
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY, CREMATORY, FACILITY FOR SCIENTIFIC USE, OR BY THE PERSON IN
CHARGE OF DISPOSING OF THE CREMATED REMAINS.
COPY 2 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR
VS9 (REV. 6/91)