Stewart, Blanche STATE OF CALIFORNIA
DEPARTMENT OF PUBLIC HEALTH
BUREAU OF VITAL STATISTICS
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Local Registrar's Permit for Removal of Cremated or Interred Human Remains
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COUNTY OF — s s+Es 1es -- ------ — --------
THIS PERMIT DOES NOT AUTHORIZE
THE REMOVAL OF REMAINS NOT CYTY OR TOwN of—_Los Age1eB__
PREVIOUSLY BURIED OR CREMATED Pr-���
DATE THIS PERMIT ISSUED_—_Uffla> 0_
In accordance with the provisions of Section 7501 of the Health and Safety Code (Statutes of 1939, Chapter 60, as
—
amended,-permission is hereby granted to M S.
egals_-----.- Stuart,--Fife
Name of applicant for this permit
to remove the cremated/Mlle/1 remains of_—__ Thomas Jalnes Stvsar},_—
Name of decedent
10-11-40
Age__sti_�.- 1______Sex Male Place of death Los loge e$ ________________Date of
Cause of death Coronary steno s___
From Forest Lawn Crematory - Los Angele$o Gig$
City or town - City or town State
to be delivered to Mr. Sam Prnyn, far di+spnsi ti On as rAgni red. by law -- ---at'destination.
Name of person,crematory,cemetery,etc.
Local Registrar of Vital Statistics Registration District No. // a
THE PERSON RECEIVING THE REMAINS AT DESTINATION MUST FILL IN AND SIGN THE FORM BELOW
AND DELIVER THIS PERMIT TO THE LOCAL REGISTRAR OF THE REGISTRATION
DISTRICT IN WHICH DESTINATION IS LOCATED
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DATE REMAINS RECEIVED------__- ! ,1Q___-----------_--_--- --
DISPOSmON OF REMAINS______ ''_-- /If; ii9'T 0
Buried,stored,etc. Write the word
SIGNED —C ^lam[
This permit should be issued in triplicate. The original must accompany the remains to destination; the duplicate should be retained
by the person delivering the remains for removal and the triplicate must be kept on file by the local registrar who issues it.
NOTE.—The law authorizing the issuance of this permit reads in part: Any person entitled by law to remove any remains may apply to the
local registrar for a permit to remove them. The local registrar shall issue a permit, retaining a copy, for which permit he shall receive a fee of fifty
cents to be paid him by the applicant for the permit.
e0989 12-99 2081
STATE PRINTING OFFICE