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Paid by General Receipt No. �96. , . , , , , , , , , , D8{ed. . . .Jc3nuaTy 27� 19g2
List Price �, 350.00
........ . Maximum No. Buriel spaces
............
Discount $..-..— Total area in sqnare fat
................
Net Paid $, , 350,.00 , , , , , , . Monument permitted . . . . . . . .
' R/R ISSUED WITH DEED (Data above Yhis line for City Record only)
N3me
KENNETH LARWIN DEED # 4
612 BAREFOOT BLVD,
5EBASTIAN, FLORIDA 32958
LOTS 1& 2, BLOCK 38, UNIT #I I
Addi ti or
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Unit �.� ,v'`; �:,�`; r� �
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Block
Lot
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Date of Mark-out ' � ` � `� <� �.i`
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Date of Burial �' {`� �`" r'�� �`'" a'"° -
: , .,�� � Ti me � - � .�y � ,:
Name of Funeral Home _ `` � r ,� :<}�~'
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Authorized by �"�- �`"` ...� ;�
_ _ __ _ ____ _
_ _ _ _ __.
W..�__ _ _ _ ._ . ._ _ _ -- — - -_ --___.__. __.._.
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PERMIT FOR DISPOSITION OF HUMAN REMAINS ��
USE BLACK INK—MAKE NO ALTERATIONS OR ERASURES �`�
NAME OF DECEDENT SEX DATE OF BIRTH DATE OF DEATH
I'��L�r'T°: L. LRRT�t?T�d N�a].e March �4, 1908 Au st 11 1988
PLACE OF DEATH—CITY OR TOWN PLACE' OF DEATH—COUNTY IOP STATE IF NOT IN CALIFORNIAI NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
La t✓,esa San Diego Thomas Lazwin son
NAME AND AODRESS OF FUNERAL DIRECTOR IOfl PERSON ACTING AS SUCH) � CALIfOfiNIA LICENSE NUMBER 5850 Bounty Street
(�rw�hrv�3v P�Inri- S(1�7 ??1 (`ainn Rl c�r9 _ Can Tli r�nn �('� ^ 7�i(1 �d71 �ieao, Caliiornia p212�
TYPE OF PERMIT, CHECK ONLY ONE OF THE FOLIOWING TYPES OF DISPOSITION ,�
� 1 BURIAL (INCLUDES ENTOMBMENT)
❑ 2. CREMATION AND BURIAL IINCLUDES INURNMENT)
❑ 5. DISINTEHMENT AND BURIAL (INCLUDES
ENTOMBMENT)
❑ 6. DISINTERMENT, CHEMATION. AND BURIAL
(INCLUDES INURNMENT)
❑ 8. DISINTERMENT AND REINTERMENT Of CREMATED
REMAINS IINCLUDES INURNMENT)
❑ 9. DISINTERMENT OF CREMATED REMAINS AND
„ DISPOSITION OTHEH THAN IN A CEMETERY
❑ 3. CREMATION ANO DISPOSITION OTHER THAN IN A
CEMETERY ❑ 7. DISINTERMENT, CREMATION, AND OISPOSITION FOR CORONER'S USE ONLY
❑ 4. SCIENTIFIC USE OTHER THAN IN A CEMETERY ❑ �0. OISPOSITION PENDING
NAME AND ADDRESS OF CEMETERY WHERE REMAINS OH CREMATED HEMAINS ARE TO BE INTERRED � COUNTY
INTERMENT � Indian 'tiver COU.IIL`
�e'oa�tian Cezne�e Se�asti�n Floria�
NAME ANO AODRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED DA7E CREMATED SIGNATURE OF PERSON IN CHARGE OF CREMATORY
CREMA7ION _;`/��� `
BURIAL AT SEA ADDflESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIfY FINAL PLACE AND COUNTY OF DISPOSITION
OR
DISPOSITION OTHER .
THAN IN A CEMETERY jT/�1 .
OF CREMATED REMAINS
SCIENTIFIC NAME AND ADDRESS OF FACILITY RECEIVING REMAINS .
usE I�T�A ' �
This is to certify that I om the penon having the right fo control fhe disposifion of the
SIGNATURE OF APPUCANT
ACKNOWLEDGMENT remains of the above named decedent under provisions of fhe Health and Safety Code, �
oF and 1 hereby acknowledge that trespass and nuisance lows apply and understand thot DATE SIGNED
APPLICANT �
fhis permit gives no right of unrestricfed occass to properfy nof owned by me.
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS AMOUNT OF FEE PAID DATE PE IT IS$ E SIGt�TURE OF L R ISTRAR ISSUING P�PMIT
LOCAL OF THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE n �- P� i� ��-!y��.' /%�/, � � � ✓•
REGISTRAR qUTHORITY FOF THE OISPOSITION SPECIFIED IN THIS PERMIT � • vo � �' `� � � ��� �iJ�'�n.��-�•-�' • "`��r'���1 y�� �"��" ��
CERTIFICATION I CERTIFY THAT THE SPECIFIED�� SIGNA U PERSON ARL,E OF D�SPOSITION LICENSE NUMBER OF CREMA7E0 REMAINS
OF PERSON IN CHARGE DISPOSITION WAS MADE ON � u � 7 � � DISPOSER. IF APPLICABLE
OF DISPOSITION l NTER DATE) '
INDICATE ADDHESS Of REGISTRAR OF COUNTY OF DEATH �
IF OISPOSITION IS
ANOTHERCCOUNTY VI.�� +\�(.,'���.cJ� G•�. LTM 05222� San ��.��� l.C�i 9213£i-5222
COPY 1 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 COMPLETED PERMIT WITHIN 10 DAYS OF DISPOSITION TO THE REGISTRAR OF THE DISTRICT IN WHICH DISPOSI-
TION OCCURRED OR THE DISTRICT NEAREST THE POINT WHERE THE CREMATED REMAINS WERE BURIED AT SEA. THE LOCAL REGISTRAH MAY DESTROY ANY
ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR.
COPY 1 STATE Of CALIfORNIA—DEPARTMENT OF HEALTH SERVICES—OfFICE Of STATE REGISTRAR OF VITAL STATISTICS
IREV. 1 86) FORM VS-9