William Thomas ElwellT_1�1111�a.
rejrzftf �
IA. NAME OF DECEDENT-FIRST(GIVEN) IS. MIDDLE 1C. LAST (FAMILY)
MIT TOLT T.
5A. CITY OF DEATH
I OF HUMAN REMAINS
OR OTHER ALTERATIONS
2. DATE OF BIRTH 1 3. DATE OF DEATH 1 4. SEX
MONTH. DAY. YEAR MONTH, DAY, YEAR
5B. COUNTY OF DEATH -OUTSIDE CALIF.,
ENTER STATE
SAN DIEGO
7A. TYPED NAME AND ADDRESS OF CALIFORNIA -FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 78. CALIF. LICENSE NUMBER
-IF APPLICABLE
NORTH CID= CREMATION SERVICE
r_ 'I r_ 111T rR�TTNJ r) VCZ WTV RT) CA 92069- PD!
6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
OF INFORMANT
CHARLOTTE GLINSKI, NIECE
7182 TERN PLACE
taking permit; 8B. DATE SIGNED
I / A /-)r)()l
I'hereby acknowledge as applicant that the proposed disposition stated herein is one ns authorized by IV I
dispositions
S
ACKNOINLEDGMENT OF APPLICANT T Section 10376 of the Health and Safiet Code and was authorized pursuant to Section 7100 of the Health and Safe Code.
9, 9 ' SI NATURE OF LOCAL REGISTRAR ISSUING PERMIT
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI- 9A. AMOUNT OF FEE PAO I BE. DATE PERMIT ISSUED I
I
PERMIT SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODE J0/10/20601 I 9� 2116842
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED
AUTHORIZATION OF IN THIS PERMIT.I M. GARCIA
LOCAL REGISTRAR NOTE: THIS GIVES Mf RRIT OF DMOSAL 0MUITSMIMUE OFCALFORMA. 7.00 01
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH-- I 9E. ADESS OF REGISTRAR OF DISTRICT OF DISPOSITION -
ANY CHANGE IN DISPOSI IF DEATH OCCURRED IN CALIFORNIA I ADDRESS TION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
TION REQUIRES ANEW P.O. BOX 85222
PERMIT TO SHOW FINAL I
DISPOSITION. SAN DIEGO, CA 92186-5222
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE ITEMS FOR CORONER'S USE ONLY
F A. BURIAL (INCLUDES ENTOMBMENT) E. TEMPORARY ENVAULTMENT ❑ 1. DISPOSITION PENDING -REMAINS LOCATED AT
12 B. CREMATION F. DISINTERMENT (Name and Address)
1:1 C. DISPOSITION OF CREMATED REMAINS OTHER ❑ G. SHIP IN TO CALIFORNIA
THAN IN A CEMETERY
1:1 D. SCIENTIFIC USE EXH. TRANSIT TO OUTSIDE OF CALIFORNIA
Em glass � 2: se: i BEEN Em al MEM
IIA.
IA. NAME AND ADDRESS OF CALIFORNIA CEMETERY 11B. DATE BURIED 111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL
I
BURIAL
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
12B. DATE CREMATED 12C. SIGNATURE OF PERSON IN CHARGE OF CREMATION
M I
W
I -
CREMATION PACIFIC CREMATORIUM INC
LU
LAKE ELsiN oRE 1 10,
CA 92530 1
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 13B. DATE RECEIVED 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
1L SCIENTIFIC
USE
W OF
14A. NAME AND ADDRESS IN RECEIVING STATE OP. COUNTRY WHERE 148. DATE SHIPPED 14C. ADDRESS PLACING WITH THE AND SIGNATUCARRIERRE OF PERSON IN CHARGE
F- REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED
W
_j TRANSIT BLAIR NEBRASKA CEMETERY
too,
0ILAIR - ---------- 7-
- �=� P1008 i:i114 15D. LICENSE NUMBER
SCATTERING AT SEA 15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUF- 156. DATE OF I 15C. SIGNATURE OF PERSON OF CREMATED RE
OR FICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION DISPOSITION I CHARGE OF DISPOSITION MAINS DISPOSER
DISPOSITION OTHER I -IF APPLICABLE
THAN IN A 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 VS (REV. 6/91)