Raymond Christian JohnsonM
USE BLACK INK ONLY -MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS
1A. NAME OF DECEDENT -FIRST (GIVEN) 1B. MIDDLE 1C. LAST (FAMILY)
2. DATE OF BIRTH
TE OF DEATH
LDATH
4. SEX
Neymnond Christian Johnson
MONTH, DAY, YEAR
0210311908
DAY YEAR
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M
5A. CITY OF DEATH 5B. COUNTY OF DEATH -OUTSIDE CALIF.,
6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
ENTER STATE_
,
G R" SvAki 8004A
OF
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Gwen L. o1 0z
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IU349 Faixf:'Prx Lane
7A. TYPED NAME AND ADDRESS OF CALIFORNIA -FUNERAL DIRECTOR OR PERSON ACTING AS SUCH: 7B. CALIF. LICENSE NUMBER
I -IF APPLICABLE
Poinnne, CA. 91766
PB GRIFFITH MOR 1-100 CENTRAL, CHPID,CA F-472
SIGNATURE OF APPLICANT -Person talking permit) 813. DATE SIGNED
hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized by
ACKNOWLEDGMENT OF APPLICANT 1 1Section
10376 of the Health and Safe U Code, and was authorized Pursuant to Section 7100 of the Health and Safety Code.
PERMIT
THIS PERMIT IS ISSUED N ACCORDANCE WITH PROVI-
I
.
9A. AMOUNT OF FEE PAID 98DATE PERMIT ISSUED' 9C. SIGNATURE OF LO JAL REGISTRAR ISSUING PERMIT
P
E NJ
SIONS OF TH CALIFOR A HEALTH AND SAFETY CODE
AUTHORIZATION OF
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED
IN THIS PERMIT.
11 M 10/24/1995 � T J
LOCAL REGISTRAR
NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA.L
I DO.
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- 19E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION -
ANY CHANGE IN DISPOSI-
TION REQUIRES A NEW
IF DEATH OCCURRED IN CALIFORNIA I IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
5
MT VIEW
PERMIT TO SHOW FINAL
, -5_1
DISPOSITION.
SA N, NAF? D IN, 0 , C A 11
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE ITEMS
FOR CORONER'S USE ONLY
F A. BURIAL (INCLUDES ENTOMBMENT) E. TEMPORARY ENVAULTIMENT
1. DISPOSITION PENDING -REMAINS LOCATED AT
FY B. CREMATION F. DISINTERMENT
(Name and Address)
C. DISPOSITION OF CREMATED REMAINS OTHER G. SHIP IN TO CALIFORNIA
I
THAN IN A CEMETERY
TRANSIT
D. SCIENTIFIC USE H. TRANSIT TO OUTSIDE OF CALIFORNIA
W
COPY 3 OF THE PERMIT IS TO BE RETURNED TO THE COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT. IF NOT
APPLICABLE, COPY 3 MAY BE DISCARDED. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OF DUPLICATE PERMIT AFTER ONE YEAR FROM
ISSUE DATE.
COPY 3 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS9 (REV.6/91)
11A. NAME AND ADDRESS OF CALIFORNIA CEMETERY
1118. DATE BURIED
111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL
BURIAL
I
E
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
12B. DATE CREMATED
12C. SIGNATURE OF PERSON IN CHARGE OF CREMATION
CREMATION
Mt Vit -,w C e mi e -%,-_ r y
.0
ighland,Smn 81!rnardino, 9 :"F 7n E. H
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS
_71313. DATE RECEIVED'
13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
SCIENTIFIC
USE
I
I
.0
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE
14B. DATE SHIPPED
14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
REMAIN&.ONCREMATF REMAINS AU TO BE SHIPPED
Rome
I
I OF PLACING WITH THE CARRIER
TRANSIT
awfnnel I-Artvan i uneral ,
444 S 17th St., B18ir, N9 6801.18
SCATTERING AT SEA
15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUF-
1513. DATE OF
15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER
OR
FICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION
I DISPOSITION
CHARGE OF DISPOSITION OF CREMATED RE -
DISPOSITION OTHER
THAN IN A CEMETERY
I MAINS DISPOSER/
-IF APPLICABLEzo-,�
W
COPY 3 OF THE PERMIT IS TO BE RETURNED TO THE COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT. IF NOT
APPLICABLE, COPY 3 MAY BE DISCARDED. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OF DUPLICATE PERMIT AFTER ONE YEAR FROM
ISSUE DATE.
COPY 3 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS9 (REV.6/91)