Burial PermitAPPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS
USE BLACK INK ONLY -MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS
1A. NAME OF DECEDENT -FIRST (GIVEN) 1B.t 1B.MIDDLE 1C. LAST (FAMILY)
2. DATE OF BIRTH
3. DATE OF DEATH
4. SEX
I I
MONTH, DAY, YEAR
7'a1" 4011-7
MONTH, DAY, YEAR
AGE
5A. CITY OF DEATHVista 15B. COUNTY OF DEATH -OUTSIDE CALIFORNIA, ENTER STATE
6. NAME, 'RELATIONSHIP, MAILING ADDRESS AND ZIP CODE
82
F INF MANTVulla_.
IS Avmw
7A. SOF I T NEVU17 TOR OR PERSON ACTING AS SUCH CALIFORNIA LICENSE NUMBER
.,,
Wft"chiul
17B.
.. I -IF APPLICABLE
s L ;
CREMATION
ACKNOWLEDGMENT
I hereby acknowledge as applicant that the proposed disposition stated herein is one
8A. SIGNATURE OF APPLICANT -Funeral Director or Person Acting as Such 18B. DATE SIGNED
OF
of the dispositions authorized by Section 10376 of the Health and Safety Code, and
OF
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
APPLICANT
was authorized pursuant to Section 7100 of the Health and Safety Code.
PI
PERMIT
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI-
9A. AMOUNT OF FEE PAID 9B. DATE PERMIT ISSUED 9C. SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
I I
AUTHORIZATION OF
SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODE
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED$4*
IN THIS PERMIT.
M -X I I "•
I
I
I 4
AtUG 0 8 199 �-au
LOCAL REGISTRAR
NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNA.
14A.
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- 19E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION --
ANY CHANGE IN DISPOSI
TION REQUIRES A NEW
IFS DEAT OCCURRED IN - ALIFORNIA I IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
Y
PERMIT TO SHOW FINAL
DISPOSITION.
S # CA 921310"w-1512-42
2-42 1 '`
10. TYPE OF DISPOSITION(S) AUTHORIZED CHECK ALL APPLICABLE ITEMS
A. BURIAL (INCLUDES ENTOMBMENT) D. SCIENTIFIC USE
❑ B. CREMATION ❑ E. TEMPORARY ENVAULTMENT
C. DISPOSITION OF CREMATED REMAINS OTHER [] F. DISINTERMENT
THAN IN A CEMETERY
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❑ G. SHIP IN TO CALIFORNIA
H. TRANSIT TO OUTSIDE OF CALIFORNIA
FOR CORONER'S USE ONLY
❑ I. DISPOSITION PENDING
COPY 3 OF THE PERMIT IS TO BE RETURNED TO THE COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT. IF NOT
APPLICABLE, COPY 3 MAY BE DISCARDED. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OF DUPLICATE PERMIT AFTER ONE YEAR FROM
ISSUE DATE.
COPY 3 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS 9 (REV. 5/89)
Burial -Removal -Transit Permit Permit Nn
AME OFD CEASED
11 A. NAME AND ADDRESS OF CEMETERY 111 B. DATE INTERRED 111 C. SIGNATURE OF PERSON IN CHARGE OF INTERMENT
DEATH COMMUNICABLE?
A: �� Oeuofttr,_kry(Carvor�r
Aug. 6, 1990
INTERMENT
SEX
AGE
PLACE OF DEATH (CITY, VILLAGE OR TOWNSHIP) (COUNTY)
Via 10401tf MIN,
82
Chula Vista San Diego
12A. NAME AND ADDRESS OF CREMATORY
I
12B. DATE CREMATED 12C. SIGNATURE OF PERSON IN CHARGE OF CREMATION
I
CREMATION
I
I
Chanhassen Cemetery Chanhassen Carver MN.
SIGNATURE OF MORTI AWOR FUNERAL DIRECTOR BUSINESS ADDRESS
10
fle 520 2nd St. Excelsior, MN, 55331
OF
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SI NA E OF REGI AR CITY, VILLAGE OR TOWNSHIP (COUNTY) (TITLE)
Poo -
Excelsior Hennepin Sub -Reg.
13A. NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
13B. DATE RECEIVED 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
SCIENTIFIC
I
I
I
I
USE
I
I
OCCURRED ON: (DATE)
I
I Poo -
14A.
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE
14B. DATE SHIPPED 14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
jj,WN*tj&JjWEhWINS ARE TO BE SHIPPED I
I OF TRANSIT
TRANSIT
1 at#
I
I�
SCATTERING AT SEA
15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION
SUFFICIENT TO IDENTIFY FINAL PLACE AND DISTRICT OF DISPOSITION I
15B. DATE OF 15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER
DISPOSITION I CHARGE OF DISPOSITION I OF CREMATED RE -
OR
DISPOSITION OTHER
I
I ( MAINS DISPOSER
I I -IF APPLICABLE
KHAN IN A CEMETERY
`
COPY 3 OF THE PERMIT IS TO BE RETURNED TO THE COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT. IF NOT
APPLICABLE, COPY 3 MAY BE DISCARDED. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OF DUPLICATE PERMIT AFTER ONE YEAR FROM
ISSUE DATE.
COPY 3 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS 9 (REV. 5/89)
Burial -Removal -Transit Permit Permit Nn
AME OFD CEASED
DATE OF DEATH
DEATH COMMUNICABLE?
Mabel Nelson
Aug. 6, 1990
1:1 YES ❑X NO
SEX
AGE
PLACE OF DEATH (CITY, VILLAGE OR TOWNSHIP) (COUNTY)
Female
82
Chula Vista San Diego
METHOD OF DISPOSAL:
PLACE OF DISPOSITION (NAME OF CEMETERY OR CREMATORY) (CITY, VILLAGE OR TOWNSHIP, COUNTY, STATE)
® BURIAL 1:1 CREMATION
El REMOVAL 1:1 OTHER (SPECIFY)
Chanhassen Cemetery Chanhassen Carver MN.
SIGNATURE OF MORTI AWOR FUNERAL DIRECTOR BUSINESS ADDRESS
10
fle 520 2nd St. Excelsior, MN, 55331
OF
A certificate of death having been filed as required by law, permission is hereby given to dispose of this body.
SI NA E OF REGI AR CITY, VILLAGE OR TOWNSHIP (COUNTY) (TITLE)
DATE ISSUED
Excelsior Hennepin Sub -Reg.
8-9-90
GNATURE OF PERSON IN CHARGE OF CONVEYANCE
AUTHORIZED DISPOSITION
SIGNATURE OF SEXTON OR CEMETERY OFFICIAL
DATE RECEIVED.
AS STATED ABOVE
OCCURRED ON: (DATE)
ri r --vv I I.7 -V.3 \ 1/04+1
This form provided by the Minnesota Department of Health, Section of Vital Statistics Original -Place of Disposition Copy -Sub Registrar