Alice Charlotte ElwellUSE BLACK INK ONLY -MAKE NO ERASURE
1A. NAME OF DECEDENT -FIRST (GIVEN) 1 18. MIDDLE I 1C. LAST (FAM;
ALICE ' CHARLOTTEELWE
5A CITY OF DEATH
ITION OF HUMAN REMAINS
ITEOUTS OR OTHER ALTERATIONS
2. DATE OF BIRTH 1 3. DATE OF DEATH 1 4. SEX
"M 2971411' 0°6i21720 1 F
15B. COUNTY OF DEATH --OUTSIDE CALIF., 6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
SAN MARCOSENTER STATE OF ;@N •oRMANT
GLINSKI, NIECE
7A. TYPED NAME AND ADDRESS OF CALIFORI SAN DIEGO CMUM
DIRECTOR OR PERSON ACTING AS SUCH; 7B. CALIF. LICENSE NUMBER 7182 TERN PLACE
NORTH COUNTY CREMATION SERVICE' -IF APPLICABLE
CARLSBAD CA 92009
635 N. TWIN OAKS VLY RDS '
AN MARCOS CA 92069 I FD1463 aA. sII3 A A ICANT-Person taking permit) 86. DATE SIGNED
ACKNOWLEDGIAENT OF APPLICANT I•hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized by �06�27�2001
Section 10376 of the Health and Safe Code and was authorized ursuant to Section 7100 of the Health and Safe Code. ±���
PERMIT THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI- 9A. AMOUNT OF FEE PAID 98. ATE P RMIT ISSUED 9C. SIGNA U E OF LOCAL REGISTRAR ISSUING PERMIT
SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODE I I 2111054
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED 106 272001
AUTHORIZATION OF IN THIS PERMIT. 7.00 I M. GARCIA 1
LOCAL REGISTRAR NOTE: PER GIVES M RIGHT OF SAL WT O; CALIFORNA.
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH -1
ANY CHANGE IN DISPOSI 1 9E. 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
P.O.r
PERMIT TO SHOW FINAL BOX 85222
DISPOSITION. 1
_1
I
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE
W
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2
W
LU
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Q
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0
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TEMS
A. BURIAL (INCLUDES ENTOMBMENT) ❑ E. TEMPORARY ENVAULTMENT❑
FOR CORONER'S USE ONLY
B. CREMATION ❑ F. DISINTERMENT
I. DISPOSITION PENDING --REMAINS LOCATED A'
(Name and Address)
El C. DISPOSITION APNINACEMETERY G. REMAINS OTHER ❑ G. SHIP IN TO CALIFORNIA
D. SCIENTIFIC USE ® H. TRANSIT TO OUTSIDE OF CALIFORNIA
IIA. NAME AND ADDRESS OF CALIFORNIA CEMETERY I 19B. DATE BURIED 111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL
BURIAL
I
I 1
CREMATION
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY 12B. DATE CREMATED 1 12C. SIGNAT PERSON IN CHARGE OF CREMATION
PACIFIC CREMATORIUM INC
LAKE ELSINORE, CA 92530 '
SCIENTIFIC
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 13B. DATE RECEIVED; 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
USE
I I'
I I
TRANSIT
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE 1 14B. DATE SHIPPED 1 14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
R'R AI A�giE SHIPPED OF PLACING WITH THE CARRIER
'ggTj3EM
KA 1 I I
BLAIR, NEBRASKA 68008 10
SCATTERING AT SEA
OR
15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUF- 15B. DATE OF 15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER
FICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION
DISPOSITION OTHER
DISPOSITION CHARGE OF DISPOSITION I OF CREMATED RE -
I I
HAN IN A CEMETERY
I MAINS
i I I -IF APPLICABLE
UUVY T OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION,
RESPONSIBLE FOR COMPLETING AND FORWARDING THE PERMIT WITHIN 10 DAYS OF DISPOSITION T
DISPOSITION OCCURRED OR THE DISTRICT NEAREST THE POINT WHERE THE CREMATED REMAI
REGISTRAR MAY DESTROY ANY ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DA -
E PERSON IN CHARGE OF DISPOSITION IS
THE REGISTRAR OF THE DISTRICT IN WHICH
i WERE SCATTERED AT SEA. THE LOCAL
COPY I STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE, REGISTRAR VS9 (REV.6/91)