Disposition PermitAPPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS
..__ ,,.iv nh0 V _ MAKE NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR OTHER ALTERATIONS
1A. NAME OF DECEDENT—FIRST
JUANITA
2. SEX 3. DATE OF BIRTH (MONTH, DAY, YEAR)6
F 07/14/192
18. MIDDLE
MARIE
DATE OF DEATH (MONTH, DAY, YEAR)
05/18/2016
3. OOUNTY OF DEATH—IF OUTSIDE OF CALIFORNIA, ENTER STATE
LOS ANGELES
LAST
PEARSON
(FETAL DEATH ONLY) DATEOF EVENT
6A. CIN OF DEATH
GLENDALE
17B. RELATIONSHIP TO DECEDENT
7A. NAME OF INFORMANT ;DAUGHTER
LYNN MILLER
7C. INFORMANT'S FULL MAILINGADDRESS—STREET NUMBER AND NAME, CITY, STATE, ZIP CODE
3616 ENCINAL STREET, LA CRESCENTA, CA 91214
ACKNOWLEDGEMENT OF APPLICANT—I hereby acknowletlge as applicant that 1 have Me
right to conVol dispositlon pursuant to Health & dab f Heath &Safety Cotle Sectianl 03055.ositicn
'PED NAME AND ADDRESS OF CALIFORNIA- 6C.irvr
SED FUNERAL DIRECTOR OR PERSON NUMBER—II
IG AS SUCH STREET NUMBER AND NAME, FD402
STATE, ZIP CODE
CRIPPEN MORTUARY
2900 HONOLULU AVE, LA CRESCENTA, CA 91214
05/24/2016
slated herein is one of the tl�sposlhons aulhonze y,,, ,,, ......_ _ -
ermit. NOTE: This permit gives no right of disposal outside
PERMIT AND AUTHORRATION OF LOCAL REGISTRAR—ANY CHANGE IN DISPOSITION REQUIR
This oermil Is Issued in accortlance wiM provisions of the Caldomia Healfh and Safety Code and is the auMorily for the tlispasilion specked in Mis p
ISSUING PERMIT
10A. AMOUNT OF
$ 12.00
X108. DATE PERMIT ISSUED
', 05123/2016
10D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH—IF DEATH DliliVRr
LOS ANGELES CO DEPT OF PUBLIC HEALTH
313 NORTH FIGUEROA STREET, RM L-1
LOS ANGELES, CA 90012
CREMATION/ RESIDENCE
NAME AND ADDRESS OF CALIFORNIA CEMETERY
IOC. SIGNATURE OF LOCAL REGISTRAR
JEFFREY GUNZENHAUSER,MD
IN CALIFORNIA 1t0E. ADDRESS OF REGISTRAR
12C. INTERMENT NUMBER—IF APPLICABLE
BURIAL OR
SCATTERING IN A
;12D. SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING
CEMETERY
(INCLUDES
►
ENTOMBMENT)
I13C. CREMATION NUMBER—IF APPLICABLE
13A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
113B. DATE CREMATED
/ ^/j� �'/ OG, /
GRAND VIEW CEMETERY AND CREMATORY,
;13D.SIGNNA'TUU'RE�•VNINCHARGEOFCREMATION
CREMATION
1341 GLENWOOD ROAD, GLENDALE, CA 91201
14A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS
148. DATE RECEIVED
E PERSON IN CHARGE OF FACILITY
;14C. SIGNATURE OF PER
SCIENTIFIC USE
,,
AND ADDRESS OF PERSON IN CHARGE OF PLACING WITH THE CARRIF
OR COUNTRY WHERE REMAINS
OR B. NAME
15A. NAME AND ADDRESS
CREMATED REMAINS ARE TO BE SHIPPED
';IBC. SIGNATURE OF PERSON IN CHARGE OF PLACING WITH 1150. DATE SHIPPI
TRANSIT
;THE CARRIER
SHORELINE, OR OTHER DESCRIPTION
,; B. DATE OF DISPOSITION 116C. LICENSE NUMBER OF CREMATED
:REMAINS DISPOSER—IF APPLICABLE
16A. ADDRESS, NEAREST POINT ON
TO IDENTIFY FINAL PLACE ANDCALIFORNIA DISTRICTOF DISPOSITION;
SUFFICIENT
SCATTERINGI IF BURIAL AT SEA, ONLY ENTER LATITUDE AND LONGITUDE
AT SEA OR MILLER 3616 ENCINAL
IN CHARGE OF SCATTERING OR BURIAL
1;16D.
BURIAL
1/2 RESIDENCE. LYNN
SIGNATURE OF PERSON
DISPOSITION
OTHERTHAN INA
STREET, LA CRESCENTA, CA 91214
;1►
CEMETERY
ERI
UPON AUTHORIZATION OF PERMIT. DISTRIBUTE COPIES AS FOLLOWS:
DOPY 1–ACCOMPANIES REMAINS TO THE STATED PLACE OF DISPOSITION. PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR COMPLETING AND FORWARDING THE P
WITHIN 10 DAYS OF DISPOSITION TO THE REGISTRAR C THE DISTRICT IN WHICH DISPOSITION OCCURRED OR THE DISTRICT NEAREST THE POINT WHERE THE CREMATED REMA
WERE SCATTERED AT SEA.'
COPY 3–RETURNAINEDA SEA.*COUNOF DEATH WOF BY PERSON IN CHARGE THE CEMETERY,
METERS CREMATORY
SED FACILITY
IN ANOTHERFSCIENTIFIC
USE
ET. IF RBAPPLICABLE,THPERSON IN CHARGE OF BE DSCARING OF THE CREMATED REMAINS.
N THE
COPY 4– RETAINED BY REGISTRAR ISSUING THE PERMIT.'
• THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE. VS 9e Rev. 011012
— e, vv 11 HFALTH. OFFICE OF VITAL RECORDS