Watson, Willis /0 7 7 cit
PERMIT FOR DISPOSITION OF HUMAN REMAINS
NAME OF DECEDENT SEX DATE OF BIRTH DATE OF DEATH
Willis Farries Watson Male May 22, 1906 April 28, 1979
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
South El Monte Los Angeles Isabel W. Reimund - sister
NAME OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) I CALIFORNIA LICENSE NUMBER 2403 Merced Ave. ,
Rose Hills Mortuary 1 970 South El Monte, California
TYPE OF PERMIT. CIRCLE ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
I. BURIAL(INCLUDES ENTOMBMENT) 5. DISINTERMENT AND BURIAL (INCLUDES 8. DISINTERMENT AND REINTERMENT OF CREMATED
CREMATION AND BURIAL (INCLUDES INURNMENT) ENTOMBMENT) REMAINS (INCLUDES INURNMENT)
6. DISINTERMENT.CREMATION.AND BURIAL
3. CREMATION AND BURIAL AT SEA OR DISPOSITION (INCLUDES INURNMENT)
OTHER THAN IN A CEMETERY(AS PROVIDED FOR IN 9. DISINTERMENT OF CREMATED REMAINS AND BURIAL
HEALTH AND SAFETY CODE) 7. DISINTERMENT.CREMATION. AND BURIAL AT SEA AT SEA OR DISPOSITION OTHER THAN IN A
OR.DISPOSITION OTHER THAN IN A CEMETERY CEMETERY (AS PROVIDED FOR IN HEALTH AND
4. SCIENTIFIC USE (AS PROVIDED FOR IN HEALTH AND SAFETY CODE) SAFETY CODE)
FOR THE PURPOSE OF ISSUING THIS PERMIT. DISINTERMENT IS DEFINED AS THE REMOVAL OF HUMAN REMAINS FROM ONE SPECIFIED PLACE OF DISPOSITION TO ANOTHER SPECIFIED PLACE
OF DISPOSITION. COMPLETE EACH ITEM REQUIRED FOR THE TYPE OF PERMIT SPECIFIED ABOVE AND INVALIDATE EACH LINE NOT REQUIRED FOR THE SPECIFIED DISPOSITION.
NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED - ;COUNTY
BURIAL
N/A i N/A
NAME AND ADDRESS OF CREMAIORY WHERE REMAINS_ARE TO BE CREMATED DATE CREMATED SIGNATV�RE OF S N IN CHARGE OF CREMATORY
CREMATION Angeles AbbeyMemorial Park Crematory -- y
1515 E. Compon Blvd. . Compton. Calif. ', " 7t �1fi
INTERMENT NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED 1 co�VTY
AFTER
CREMATION Pine View Cemetery Glens, Falls, New York I
BURIAL AT SEA ADDRESS. NEAREST POINT ON SHORELINE. OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF DISPOSITION
OR
DISPOSITION OTHER
THAN IN A CEMETERY
OF CREMATED REMAINS N/A N/A
This is to certify that I am the person having the right to control the disposition of the SIGNATURE OF APPLICANT ./.)
•
ACKNOWLEDGMENT �
remains of the above named decedent under provisions of the Health and Safety Code, (ti/i r f�j�jyy����
OF j
APPLICANT and 1 hereby acknowledge that trespass and nuisance laws apply and understand that DATE SIGNED
this permit gives no right of unrestricted access to property not owned by me. May 1, 1979
SCIENTIFIC NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
USE N/A
LOCAL THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF AMOUNT OF FEE PAID D�AATvE PERMIT ISSUED
SIGNATU I G PERMIT i
REGISTRAR THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE $2.00 M71) 2 1979kb. 1
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT 777 111!lllll L
CERTIFICATION �1 v/�aSIGNATf OF PERSON IN CHARGE SPOSITION
OF PERSON IN CHARGE I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON - G TER DATE)DISPOSITION TER DATE) '• ,2j�L
COPY I OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION. THE PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR COMPLETING THE PERMIT AND FORWARDING THE COM-
PLETED PERMIT WITHIN 10 DAYS TO THE LOCAL REGISTRAR OF THE DISTRICT IN WHICH DISPOSITION OCCURRED OR TO THE LOCAL REGISTRAR OF it E DISTRICT NEAREST THE POINT WHERE THE CREMATED RE-
MAINS WERE BURIED AT SEA.
COPY 1 STATE OF CALIFORNIA—DEPARTMENT OF HEALTH—OFFICE OF THE STATE REGISTRAR OF VITAL STATISTICS (REV. 4-1-75) FORM VS-9