Larsen, Marie E APPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS
USE BLACK INK ONLY—MAKE NO ERASURES,VA I_IEOUTS,PHO I OCOPIES,OR OTHER ALTERATIONS
IA NAML OF Of CIA)FNI--FIRST :1(_LAS1
MARIE ELAINE : LARSEN
2 SLX 3,DAI E Of:BIR I[I (MONTH,DAY,YLAR) 4,DAI E OF DLAHI (MONTH,DAY,YEAR) S.(FETAL DEATH ONLY)DAI L OF LVEN F(MON)H,DAY,YEAR)
F 09/24/1927 04/23/2019
CA CITY OF DEATH :6B.COUNTY OF DEATH—IF OUTSIDE OF CALIFORNIA,ENTER STATE
HANFORD KINGS
,'A NAME OF INFORMANT :713 RELATIONSHIP TO DECEDENT 8A.TYPED NAME AND ADDRESS OF CALIFORNIA- 8B CALIFORNIA LICENSE
LICENSED FUNERAL DIRECTOR OR PERSON NUMBER—IF APPLICABLE
MARCUS E. LARSEN :SON ACTING AS SUCH—STREET NUMBER AND NAME,
CITY,STATE,ZIP CODE FD521
/C INFORMANT'S FULL MAILING ADDRESS—STREET NUMBER AND NAME,CITY,STATE,ZIP CODE
341 N. 19 1/2 AVE., #353, LEMOORE, CA 93245 PHIPPS-DALE FUNERAL CHAPEL
420 W D ST, LEMOORE, CA 93245
ACKNOWLEDGEMENT OF APPLICANT—I hereby acknowledge as applicant that I have the 9AAPPLICANT SIGNATURE :913,DATE SIGNED
right to control disposition pursuant to Health&Safety Code Section 7100,and that the disposition
stated herein is one of the dispositions authorized by Health&Safety Code Section 103055 04/29/2019
PERMIT AND AUTHORIZATION OF LOCAL REGISTRAR—ANY CHANGE IN DISPOSITION REQUIRES A NEW PERMIT TO SHOW FINAL DISPOSITION
this permit is issued in accordance with provisions of the California Health and Safety Code and is the authority for the disposition specified in this permit NOTE:This permit gives no right of disposal outside
of California.
1 OA AMOUNT Of-FEE PAT[) :10B DAIF PERMIT ISSUED :10C.SIGNATURE OF LOCAL RECISIRAR ISSUING PERMIT
$ 12.00
04/29/2019 MILTON TESKE, MD
101) ADDRESS OF REGISTRAR OF DISTRICT OF DEA-T I I—IF DEATH OCCURRED IN CALIF ORNIA 1 OE,ADDRESS OF RFGISTRAIR OF DISI RIC r OF D ISPOS I T ION--IF DIFFERENT FROM 101)
KINGS HEALTH DEPARTMENT
330 CAMPUS DRIVE
HANFORD, CA 93230
11 AUTHORIZED DISPOSITIONS) FOR CORONER'S USE ONLY
CREMATION/RESIDENCE
12A,NAME AND ADDRESS OF CALIFORNIA CEMETERY :12B DAH-130RIED :12C IN I FIRMENT NLJM131 R—IF APPI CABI F
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INC[UDFS :12D SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING
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13A,NAME AND ADDRESS OF CALIFORNIA CREMATORY :13B DATE CYFMA :13C.CREMATION NUMRI R-IF APPLICAIT1.1
CRF MAT ION KAWEAH CREMATION, 127 E. CALDWELL AVE.,
VISALIA, CA 93277 :1 3D.SIGNATURE OF PERSON IN CHARGE OF CREMATION
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Larsen
NAME Marie E. Larsen Age: 92
Lot Owner: Robin Larsen/Marcus Larsen
Lot# 1 07C Algonquin Grave# 2
Case:
Urn
Died:4/23/2020 I4e /2020
Funeral Home:
Phipps—Dale Chapel
Cemetery:
Pine View
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Larsen
NAME Dwight Larsen Age: 67
Lot Owner: Marcus/Robin Larsen
Lot# 1 07C Algonquin Grave# 1
Case: Urn
Died: 1 0/7/1 9 9 4 411,-,pgred72020
Funeral Home: Unknown
Cemetery:pine View