Permit for Disposition of RemainsAPPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS
USE BLACK INK ONLY—MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS
1A. NAME OF DECEDENT—FIRST (GIVEN) 18. MIDDLE IC. LAST (FAMILY)
2. DATE OF BIRTH
3. DATE OF DEATH
C SEX
CLAM
M. I
KNAPP
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FEMALE
5A- CITY OF DEATH
SB. COUNTY OF DEATH—OUTSIDE CALIFORNIA. ENTER STATE
16. NAME. RELATIONSHIP. MAILING ADDRESS AND ZIP CODE
SAN DIEGO
I
SAN DIMO
I
I I Riffin. CO(IRw, Il4U m R
4545 AIHAMBRA S7REEC
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78. CALIFFOORRNIAAALICENSE NUMBER
i —4F E
SAN DIlI;O CA
92107
C�O1D
SAN DIMO, CA 92107
ACKNOWLEDGMENT
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SIGIO� E OF APPLICANTrFulwr&I (n Po MINI (iny as SuCA 188. DATE SIGNED
OF
eI dw dupe oNMmG.d by Semen 10376 el " led a Selly Ced., ad
C NOV 7, 19%
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APPLICANT
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SAN DIED, CA
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI
9A. AMOUNT OF FEE PAID DATE PERMIT ISSUED' 9C. SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
PERMIT
$IONS OF TIE CALIFORNIA HEALTH AND SAFETY CODEw
AND IS THE AUTHORITY FOR THE DISPOSITION SPEOFIED
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19B.
(y P,
Nov Q 7 1991A ��J
AUTHORIZATION OF
IN THIS PERMIT.
♦;,uf„^�-..;C, T�t^�.e'•'�R�A���1 C
LOCAL REGISTRAR
NILE: TNS PRIM HIES NO NNR OF 06M& IINIDE a CAi'OIOIA
►
►
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE 148. DATE SHIPPED
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH—
19E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION—
ANY CHANIGRfN ^1
TION NEW
PERAVTTOSHOW FINAL
IF DEATH OCCURRED IN CAUFORNIA
P.O. BOX 85222, SAN DIEDO, CA 92138-5222
MR MCI
I IF WSRO61TKMl R TO OCCUR IN ANOTDG IN CA(MOIIHNA
I
DISPOSITION
I
I
10. TYPE OF DISPOSITION(S) AUTHORIZED OIECI( ALL APPLICABLE ITEMS
lfi A. BURIAL (NCLUOES ENTOMEI ENT) n D. SCIENTIFIC USE
❑ G. SHP N TO CALIFORNIA
E H. TRANSIT TO OUTSIDE OF CALIFORNIA
L B. CREMATION
❑ E. TEMPORARY ENVAULTMENT
FOR CORONER'S USE ONLY
❑ C. DIISSMSITION OF CREMATED REMAINS OTHER ❑ F. DISINTERMENT
❑ I. DISPOSITION PENDING
THAN IN A CEMETERY
11A. NAME AND ADDRESS OF CEMETERY r1B. DATE INTERRED, 11C. SIGNATURE OF PERSON N CHARGE OF INTERMENT
CliMMSEN (Dffi=, CikWSSEN,
I
INTERMENT
CARVER CO I
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/2A. NAME AND ADDRESS OF CREMATORY DATE CREMATED
SIGNATURE OF PERSON IN CHARGE OF CREMATION
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1128,
I]REEWOM Ge%TM 1-805 & DTERTAT. AVESAIE, I
112C.
CREMATION
t`C"1 -- 81890
SAN DIED, CA
i ►
13A. NAME AND ADDRESS OF FACILITY RECEIVING REMAINS 138. DATE RECEIVED'
13C. SIGNATURE OF PER CHARGE OF FACLTTY
SCIENTIFIC
1
I
USE
►
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14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE 148. DATE SHIPPED
14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
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REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED 1
OF TRANSIT
i TRANSIT
SEN C ', C[ EN, NN I
I
U
CARVER OOM I
I ►
SCATTERING AT SEA
15A. ADDRESS. NEAREST POINT ON SHORELINE. OR OTHER DESCRIPTION 158. DATE OF
1SC. SIGNATURE OF PERSON IN NSE FAMBER
SUFFICIENT TO IDENTIFY FINAL PLACE AND DISTRICT OF DISPOSITION DISPOSITION
HA113D.
CHARGE OF DISPOSITION OF wD FD EE
OR
I
I MANS A15
DISPOSITION OTHER
I —IF AMICAaIE
IRAN IN A CEMETERY
►
COPY 1 OF THE PERMIT ACUUMPANIES IHE HEMAINS IV Int SIAILU rLAVC Vr J10rVO111Vn. Inc rcnOwm In
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. 5189)