Hans Edward SorensenSITZUMAN REMAINS
USE BLACK INK—MAKE NO ALTERATIONS OR ERASURES
NAME OF DECEDENT - SEX DATE OF BIRTH DATE OF DEATH-
HMIS EDWM SORENle Sept. 15,1891 1, 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 AngelesAngeles
y� o -n Edwards -- gh er
-,NAME AND ADDRESS OF FUNERAL DIRECTOR IOR PERSON ACTING AS SUCH) I CALIFORNIA LICENSE NUMBER 1705 Heather RidgeDr.
Kiefer :6 Eyerick Mortuary 61 Glendale,CA91207
TYPE OF PERMIT, CHECK ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
1. BURIAL (INCLUDES ENTOMBMENT) ❑ 5. DISINTERMENT AND BURIAL (INCLUDES ❑ 8. DISINTERMENT ANDREINTERMENTOF CREMATED
ENTOMBMENT) REMAINS (INCLUDES INURNMENT)
❑ 2. CREMATION AND BURIAL (INCLUDES INURNMENT) ❑ 6. DISINTERMENT, CREMATION, AND BURIAL �;' ❑- 9. DISINTERMENT OF CREMATED REMAINS AND
(INCLUDES INURNMENT) DISPOSITION OTHER THAN IN.A CEMETERY
❑ 3. CREMATION..AND-DISPOSITION OTHER THAN INA
CEMETERY - ❑ T DISINTERMENT, CREMATION, AND DISPOSITION FOR C®BONER'S. USE ONLY
❑ 4. SCIENTIFIC USE OTHER THAN IN A CEMETERY
- ❑ 10. DISPOSITION PENDING
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 CEMETERY WHERE REMAINS OR CREMATED REMAINS ARE TO BE INTERRED I COUNTY
INTERMENT
Bl a ,' aB.1a_ 3.r, s e d V' '= shon
NAAND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED
DATE CREMATED
SIGNATURE OF PERSON IN CHARGE OF CREMATORY
CREMATION
7E
BURIAL AT SEA
ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF DISPOSITION
OR
DISPOSITION OTHER
h,
J A::
THAN IN A CEMETERY
OF. CREMATED REMAINS
SCIENTIFIC
NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
/
USE
This is to certify that I am the person having the right to control the disposition of the
SIGNATURE OF APPLICANT-
ACKNOWLEDGMENT
remains. of the above named decedent under provisions of the Health and Safety Code,.,:
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.
µAMOUNT
LOCAL.
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS
OF FEE PAID
DATE PERMIT ISSUED
SIGNATI,�RE OF;I,OCR4 REGISTRARIS,S,I11NG PERMIT
OF THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE
,".
,E F" - '" - -
REGISTRAR
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT =
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CERTIFICATION
I CERTIFY THAT THE SPECIFIED
SIGNATURE OF PEMh' I CHAR DISPOSITION
LICENSE NUMBER OF CREMATED REMAIIhS
OF PERSON IN CHARGE
DISPOSITION WAS MADE ON - "'
---
DISPOSER, IF APPLICABLE
OF DISPOSITION
(ENTER DATE).,"'
ei
INDICATE ADDRESS OF REGISTRAR OF COUNTY OP DEATH -
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