Flint, Mychael APPLICATION AND PERMIT FPR[1: POSITION OF HUMAN REMAINS .�} �)I3'
USE BLACK INK ONLY-MAKE NO ERASURES WHITEOUTS,PHOTOCOPIES,OR OTHER ALTERATIONS 1
IA.NAME OF DECEDENT-FIRST )1B.MIDDLE IC.LAST
MYCHAEL ANTHONY FLINT
2.SEX 3.DATE OF BIRTH (MONTH,DAY,YEAR) 4.DATE OF DEATH (MONTH,DAY,YEAR) 5.(FETAL DEATH ONLY)DATE OF EVENT(MONTH,DAY,YEAR)
M 01/17/1990 03/07/2011
6A.CITY OF DEATH 68.COUNTY OF DEATH-IF OUTSIDE OF CALIFORNIA,ENTER STATE
CAMP PENDLETON SAN DIEGO
7A.NAME OF INFORMANT 7B.RELATIONSHIP TO DECEDENT 8A.TYPED NAME AND ADDRESS OF CALIFORNIA- 8B.CALIFORNIA LICENSE
LICENSED FUNERAL DIRECTOR OR PERSON NUMBER-IF APPLICABLE
JASON TETZLAFF DECEDENT ACTING AS SUCH-STREET NUMBER AND NAME,AFFAIRS OFFICER CITY,STATE,ZIP CODE FD843
7C.INFORMANT'S FULL MAILING ADDRESS-STREET NUMBER AND NAME,CITY,STATE,ZIP CODE GREENWOOD MORTUARY
34800 BOB WILSON DRIVE 4300 IMPERIAL AVENUE
SAN DIEGO, CA 92134 SAN DIEGO, CA 92113
ACKNOWLEDGEMENT OF APPLICANT-I hereby acknowledge as applicant that I have the 9A. SIGNATURE 9B.DATE SIGNED
right to control disposition pursuant to Health&Safety Code Section 7100,and that the disposition 03/11/2011
stated herein is one of the dispositions authorized by Health&Safety Code Section 103055. ►
PERMIT AND AUTHORIZATION OF LOCAL REGISTRAR-ANY CHANGE IN DISPOSITION REQUIRES A NEW PER TO OW 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.
10A.AMOUNT OF FEE PAID 10B.DATE PERMIT ISSUED i OC.SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
$ 11.00 03/11/2011 ► WILMA WOOTEN, MD
c
10D.ADDRESS OF REGISTRAR OF DISTRICT OF DEATH-IF DEATH OCCURRED IN CALIFORNIA 10E.ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION-IF DIFFERENT FROM 10D
SAN DIEGO COUNTY VITAL RECORDS
3851 ROSECRANS ST
SAN DIEGO, CA 92110 --
11.AUTHORIZED DISPOSITION(S) FOR CORONER'S USE ONLY
TRANSIT
12A.NAME AND ADDRESS OF CALIFORNIA CEMETERY 12B.DATE BURIED 12C.INTERMENT NUMBER-IF APPLICABLE
BURIAL OR
SCATTERING IN A
CEMETERY(INCLUDES 12D.SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING
ENTOMBMENT)
►
13A.NAME AND ADDRESS OF CALIFORNIA CREMATORY 13B.DATE CREMATED 13C.CREMATION NUMBER-IF APPLICABLE
CREMATION 13D.SIGNATURE OF PERSON IN CHARGE OF CREMATION
►
14A.NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 14B.DATE RECEIVED
SCIENTIFIC USE 14C.SIGNATURE OF PERSON IN CHARGE OF FACILITY
►
15A.NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE REMAINS OR 15B.NAME AND ADDRESS OF PERSON IN CHARGE OF PLACING WITH THE CARRIER
CREMATED REMAINS ARE TO BE SHIPPED
CARLETON FUNERAL HOME
TRANSIT 68 MAIN STREET
15C.SIGNATURE OF PERSON IN CHARGE OF PLACING WITH 15D.DATE SHIPPED
HUDSON FALLS, NY 12839 THE CARRIER
16A.ADDRESS,NEAREST POINT ON SHORELINE,OR OTHER DESCRIPTION 16B.DATE OF DISPOSITION 16C.LICENSE NUMBER OF CREMATED
SUFFICIENT TO IDENTIFY FINAL PLACE AND CALIFORNIA DISTRICT OF DISPOSITION; REMAINS DISPOSER-IF APPLICABLE
SCATTERING/ IF BURIAL AT SEA,ONLY ENTER LATITUDE AND LONGITUDE
BURIAL AT SEA OR
DISPOSITION
OTHER THAN IN A 16D.SIGNATURE OF PERSON IN CHARGE OF SCATTERING OR BURIAL
CEMETERY
►
UPON AUTHORIZATION OF PERMIT,DISTRIBUTE COPIES AS FOLLOWS:
COP 1-/ACCOMPANIES REMAINS TO THE STATED PLACE OF DISPOSITION. PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR COMPLETING AND FORWARDING THE PERMIT
WITH f6 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."
COPY 2-RETAINED BY PERSON IN CHARGE OF THE CEMETERY,CREMATORY,FACILITY FOR SCIENTIFIC USE,OR BY THE PERSON IN CHARGE OF DISPOSING OF THE CREMATED REMAINS.
COPY 3-RETURN TO COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT.IF NOT APPLICABLE,COPY 3 MAY BE DISCARDED."
COPY 4-RETAINED BY REGISTRAR ISSUING THE PERMIT.`
"THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE.
STATE OF CALIFORNIA,DEPARTMENT OF PUBLIC HEALTH,OFFICE OF VITAL RECORDS VS 9e Rev.01/01/2008