Georgia Gilda ClausenPERMIT FOR DISPOSITION OF HUMAN REMAINS
USE BLACK INK—MAKE NO ALTERATIONS OR ERASURES
NAME OF DECEDENT SEX DATE OF BIRTH DATE OF DEATH
GEORGIA GILDA CLAUSEN": JAN.15,1890 JAN.9,,1988
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
LOS� " I S CAROLINE, y SCE -DAUGHTER
NAME AND ADDRESS OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) CALIFORNIA LICENSE NUMBER 12763 M �'` L, AVE,�"
GATES KINGSLEY GATES S 3 ACAS 1 ;S S, . 9 0
I
TYPE OF PERMIT, CHECK ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
C� 1. BURIAL (INCLUDES ENTOMBMENT)
❑ 2. CREMATION AND BURIAL (INCLUDES INURNMENT)
❑ 5. DISINTERMENT AND BURIAL (INCLUDES
ENTOMBMENT)
❑ 6. DISINTERMENT, CREMATION, AND BURIAL
(INCLUDES INURNMENT)
❑ B. DISINTERMENT AND REINTERMENT OF CREMATED
REMAINS (INCLUDES INURNMENT)
❑ 9. DISINTERMENT OF CREMATED REMAINS AND
DISPOSITION OTHER THAN IN A CEMETERY
❑ 3. CREMATION AND DISPOSITION OTHER THAN IN A
CEMETERY ❑ 7. DISINTERMENT, CREMATION, AND DISPOSITION FOR CORONER'S USE ONLY
❑ 4. SCIENTIFIC USE OTHER THAN IN A CEMETERY ❑ 10. DISPOSITION PENDING
NAME AND ADDRESS OF CEMETERY WHERE REMAINS OR CREMATED REMAINS ARE TO BE INTERRED I UUUINIT
INTERMENT _ � �:� xf'v EC4 el t 3 €�4'-A T CE7 \ I W.AS F1 T "qrT ON
INDICA AUUHt55 UE HtUIJ InAn Ur wU I i
IF DISPOSITION IS -
TO OCCUR IN
ANOTHER COUNTY
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY WHERE THE HUMAN REMAINS ARE INTERRED, OR BY THE PERSON IN CHARGE OF THE
CREMATORY WHERE THE REMAINS ARE CREMATED, OR BY THE PERSON IN CHARGE OF THE FACILITY WHERE THE REMAINS ARE UTILIZED 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 OF VITAL STATISTICS (REV. 1-86) FORM VS -9
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED
DATE CREMATED
SIGNATURE OF PERSON IN CHARGE OF CREMATORY
CREMATION
oil
10,
BURIAL AT SEA
ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF DISPOSITION
OR
DISPOSITION OTHER
THAN IN A CEMETERY
OF CREMATED REMAINS
NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
SCIENTIFIC
USE
SIGNATURE OF APPLICANT
This is to certify that I am the person having the right to control the disposition of the
ACKNOWLEDGMENT
remains of the above named decedent under provisions of the Health and Safety Code,
10.
DATE SIGNED
OF
and I hereby acknowledge that trespass and nuisance laws apply and understand that
APPLICANT
this permit gives no right of unrestricted access to property not owned by me.
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS AMOUNT OF FEE PAID DAT P IT ISRED SIGNATU E OF�QCAi REGISTRAR 1S$U N� PER,hI LT
LOCAL
OF THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE
REGISTRAR4
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT .100
SIGNATURE OF PERSON IN CHARGE OF DISPOSITK) '' �LICE14§E NUMBER Of CREMATE_. REMAINS
CERTIFICATION
I CERTIFY THAT THE SPECIFIED J J _ •-EyrgpOSE"ff; IFAPPLICABLE—
OF PERSON IN CHARGE
DISPOSITION WAS MADE ON�
(ENTER DATE)
OF DISPOSITION
INDICA AUUHt55 UE HtUIJ InAn Ur wU I i
IF DISPOSITION IS -
TO OCCUR IN
ANOTHER COUNTY
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY WHERE THE HUMAN REMAINS ARE INTERRED, OR BY THE PERSON IN CHARGE OF THE
CREMATORY WHERE THE REMAINS ARE CREMATED, OR BY THE PERSON IN CHARGE OF THE FACILITY WHERE THE REMAINS ARE UTILIZED 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 OF VITAL STATISTICS (REV. 1-86) FORM VS -9