Janet Diane LenskiUSE BLACK INK ONLY -MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS
1A. NAME OF DECEDENT -FIRST (GIVEN) 1B. MIDDLE IC. LAST (FAMIIAl IJAR
yLY) 2. /Dy�ATE pOp*F BIRTH 3,,. DATE
g OF DEATH 4. SEX
Janet Diane LENSK
96
5A. CITY OF DEATH 15B. COUNTY OF DEATH -OUTSIDE CALIF., 6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
Ar
caths I ENT�Ro AT AngelesOF MarilANT yn
Levin - Sister
7A. TYPED NAME AND ADDRESS OF CALIFORNIA -FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 7B. CALIF. LICENSE NUMBER 140 West Floral Avenue
aye
O'CONNOR LAGUNA HILLS MORTUARY -IF APPLICABLE
Arcadia, California 91006
25301 Alicia, Laguna Hills, CA 92653 1293
8A. SIGNATURE OF APPLICANT -Person taking permltl 8B. DATE SIGNED
I
ACKNOWLEDGMENT OF APPLICANT hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized by P +11 7/20114992
Section 10376 of the Health and Safe Gode and was authorized Pursuant to Section 7100 of the Health and Safe Code..r.y'.�" I
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI- 9A. AMOUNT OF FEE PAID 9B. DATE PERMIT ISSUED 9C. SIGNATURE OF LOCAL, -.,REGISTRAR ISSUING PERMIT
PERMIT SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODE
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED I I
AUTHORIZATION OF IN THIS PERMIT. $7.001UL 2 1 199
I ,
LOCAL REGISTRAR NOTE: THIS PERMIT ONES RIGHT OF DISPOSAL OUTSIDE Of CWLIFOREOW.
ANY CHANGE IN DISPOSI 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- 19E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION-
TION REQUIRES A NEW Los
.: IF DEATH OCCURRED IN CALIay IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA ""=7
PERMIT TO SHOW FINAL Angeles.* FOR I3 s Figueroa St. I
DISPOSITION. sAngeles,CA.1. I
i#
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE ITEMS FOR CORONER'S USE ONLY
FIA. BURIAL (INCLUDES ENTOMBMENT) E. TEMPORARY ENVAULTMENT I. DISPOSITION PENDING -REMAINS LOCATED AT
B. CREMATION F1 F. DISINTERMENT (Name and Address)
L1 C. DISPOSITION OF CREMATED REMAINS OTHER ❑ G. SHIP IN TO CALIFORNIA
THAN IN A CEMETERY
D. SCIENTIFIC USE °H. TRANSIT TO OUTSIDE OF CALIFORNIA
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY, CREMATORY, FACILITY 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 VS9 (REV.6/91)
IIA. NAME AND ADDRESS OF CALIFORNIA CEMETERY
1 11 B. DATE BURIED
1 11C. SIGNATURE OF PERSON IN CHARGE OF BURIAL
BURIAL
I
None
I
I
�2
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
12B. DATE CREMATED
I
12C. SIGNATURE OF PERSON IN CHARGE OF CREMATION
I
CREMATION
I
I
w
None
I
r
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS
13B. DATE RECEIVED
13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
SCIENTIFIC
I
I
USE
None
I
I
I
.0
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE
148. DATE SHIPPED
14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
L
REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED
OF PLACING WITH THE CARRIER
-i
TRANSIT
Campbell 1-lortuary
C of er f ;t/
444 a:�ar g : ska
a�
IveD L6
a
SCATTERING AT SEA
15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUF-
15B. DATE OF
15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER L'
OR
FICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION
I DISPOSITION
I
CHARGE OF DISPOSITION I OF CREMATED RE- s
I MAINS DISPOSER
DISPOSITION OTHER,
I
I -IF APPLICABLE
HAN IN A CEMETERY
I
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY, CREMATORY, FACILITY 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 VS9 (REV.6/91)