UPON AUTHORIZATION OF PERMIT, DISTRIBUTE COPIES AS FOLLOWS:
COPY 1 – ACCOMPANIES REMAINS TO THE STATED PLACE OF DISPOSITION. PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR COMPLETING AND FORWARDING THE PERMIT
WITHIN 10 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 9 Rev. 01/01/2008
APPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS
USE BLACK INK ONLY — MAKE NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR OTHER ALTERATIONS
1A. NAME OF DECEDENT—FIRST 1B. MIDDLE 1C. LAST
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)
6A. CITY OF DEATH 6B. COUNTY OF DEATH—IF OUTSIDE OF CALIFORNIA, ENTER STATE
7A. NAME OF INFORMANT 7B. RELATIONSHIP TO DECEDENT 8A. TYPED NAME AND ADDRESS OF CALIFORNIA-
LICENSED FUNERAL DIRECTOR OR PERSON
ACTING AS SUCH—STREET NUMBER AND NAME,
CITY, STATE, ZIP CODE
8B. CALIFORNIA LICENSE
NUMBER—IF APPLICABLE
7C. INFORMANT’S FULL MAILING ADDRESS—STREET NUMBER AND NAME, CITY, STATE, ZIP CODE
ACKNOWLEDGEMENT OF APPLICANT–I hereby acknowledge as applicant that I have the
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.
9A. APPLICANT SIGNATURE
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9B. DATE SIGNED
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.
10A. AMOUNT OF FEE PAID
$
10B. DATE PERMIT ISSUED 10C. SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
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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
11. AUTHORIZED DISPOSITION(S)—CHECK APPLICABLE ITEMS FOR CORONER’S USE ONLY
A. BURIAL OR SCATTERING IN A CEMETERY
(INCLUDES ENTOMBMENT)
B. CREMATION
C. DISPOSITION OF CREMATED REMAINS
OTHER THAN IN A CEMETERY
D. SCIENTIFIC USE
E. TEMPORARY ENVAULTMENT
F. DISINTERMENT
G. SHIP IN TO CALIFORNIA
H. TRANSIT OUTSIDE OF CALIFORNIA
I. DISPOSITION PENDING—LOCATION OF REMAINS—
NAME AND ADDRESS
12B. DATE BURIED 12C. INTERMENT NUMBER—IF APPLICABLE
BURIAL OR
SCATTERING IN A
CEMETERY
(INCLUDES
ENTOMBMENT)
12A. NAME AND ADDRESS OF CALIFORNIA CEMETERY
12D. SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING
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13B. DATE CREMATED 13C. CREMATION NUMBER—IF APPLICABLE
CREMATION
13A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
13D. SIGNATURE OF PERSON IN CHARGE OF CREMATION
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14B. DATE RECEIVED
SCIENTIFIC USE
14A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS
14C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
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15B. NAME AND ADDRESS OF PERSON IN CHARGE OF PLACING WITH THE CARRIER
TRANSIT
15A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE REMAINS OR
CREMATED REMAINS ARE TO BE SHIPPED
15C. SIGNATURE OF PERSON IN CHARGE OF PLACING WITH
THE CARRIER
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15D. DATE SHIPPED
16B. DATE OF DISPOSITION 16C. LICENSE NUMBER OF CREMATED
REMAINS DISPOSER—IF APPLICABLE
SCATTERING/
BURIAL AT SEA OR
DISPOSITION
OTHER THAN IN A
CEMETERY
16A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION
SUFFICIENT TO IDENTIFY FINAL PLACE AND CALIFORNIA DISTRICT OF DISPOSITION;
IF BURIAL AT SEA, ONLY ENTER LATITUDE AND LONGITUDE
16D. SIGNATURE OF PERSON IN CHARGE OF SCATTERING OR BURIAL
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