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Michael Carie StonerAPPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS USE BLACK INK ONLY — MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS DATE OF BIRTH 3. DATE OF DEATH EAR 10%30/1967 06/27/2007 1A. NAME OF DECEDENT — FIRST (GIVEN) AB. MIDDLE MICHAEL I CARIE LAST (FAMILY) STONER 5A. CITY OF DEATH 15B. COUNTY OF DEATH —OUTSIDE CALIF., 6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE ;ENTER STATE OF INFORMANT VACAVILLE ;SOLANO LANI STONER, FOSTER MOTHER 7A TYPED NAME AND ADDRESS OFCALIFORNIA—FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 78. CALIIF PF. ICAB ECENSE CENSE NUMBER 1616 CORTEZ AVE. BRYAN-BRAKER FUNERAL HOME, 1850 W TEXAS ST POI FD988 8AS GOCK GON LICA 95209v1�n 18B.DATESIGNED BOX 7 FAIRFIELD, CA 94533 : 06/29/2007 I hereby aammiedge as applicant that the proposed stated herein is on of the dispositions authorized by Section 103055 , j ACKNOWLEDGEMENT OF APPLICANT of the Health and Safety Code, and Nes authorized pursuant to Section 7100 of the Health and Safety Code. THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF 9A. AMOUNT OF FEE PAID •,9171. DATE PERMIT ISSUED ;9C. SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE AUTHOR- EQ ITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT. $11.00 06/29/2007 i;ONALD W CHAPMAN PERMIT NOTE; THIS PERMITGIVE NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA I AUTHORIZATION OF LOCAL REGISTRAR 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH -• voeAln occuaam a w.ronew ANYCHAANSOLANO HEALTH DEPARTMENT ITION REQUIRES I NEW EW PERMIT TO SHOW FINAL DISPOSITION 355 TUOLUMNE STREET VALLEJO, CA 94590 10. AUTHORIZED DISPOSITION(S) CREMATION/TRANSIT ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION -- msvosnioH w to occue ea nnomm oisrnic* x cu�osnw CORONER'S USE ONLY COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION, THE PERSON IN CHARGE OF DISPOSITION IS RESPONSitsLIM FOR COMPLETING AND OR THE DISTRICT EARESTT/HE POINT WHERE ARDING THE ITHE CCIT IREIMAT DN 10 AREMAINS WERE SYS OF CATTERED ATN TO THE G SEA. THE HE LOCALL REGISTRAR MAY DESTROY ANY RIG ORIR OF THE DISTRICT IN WHICH DISPOSITION GINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE, VS9e (REV.12/04) COPY 1 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF VITAL RECORDS SPECIAL INSTRUCTIONS REGARDING CREMATION THE FOLLOWING N OF REMAINS OTHER THAN IN OA CEMETRY ERYANDAPPLICABLENS ARE AND BURIAL ATSEA AFT R CREMATION AS PROVIDED NCREMATED HEALTH AND SAFETY CODE SECTIONS 7054.6, 7116, 7117, AND 103060. NO PERSON SHALL DISPOSE OF OR OFFER TO DISPOSE OF ANY CREMATED HUMAN REMAINS UNLESS REG- ISTERED AS A CREMATED REMAINS DISPOSER BY THE STATE CEMETERY BOARD. THIS ARTICLE SHALL NOT APPLY TO ANY PERSON, PARTNERSHIP, OR CORPORATION HOLDING A CERTIFICATE OF AUTHORITY AS A CEMETERY, CREMATORY LICENSE, CEMETERY BROKER'S LICENSE, CEMETERY SALESMAN'S LICENSE, OR FUNERAL DIRECTOR'S LICENSE, NOR SHALL THIS ARTICLE APPLY TO ANY PERSON HAVING THE RIGHT TO CONTROL THE DISPOSITION OF THE CREMATED REMAINS OF ANY PERSON OR THAT PERSON'S DISIGNEE IF THE PERSON DOES NOT WITHIN ANY CALENDAR YEAR.OSE (BUSSIINEOR OFFER TO DISPOSE S AND PROFESSIONS COO EORE ECTIHAN 10 ON 9740.)EMATED HUMAN REMAINS CREMATED REMAINS MAY BE SCATTERED IN AREAS WHERE NO LOCAL PROHIBITION EXISTS, PROVIDED THAT THE CREMATED REMAINS ARE NOT DISTINGUISHABLE TO THE PUBLIC, ARE NOT INA CONTAINER, AND THAT THE PERSON WHO HAS CONTROL OVER TTEN P THE PRDISPOSOPERTY OWNER ORTION OF THE TGOVERNING AGENCYED REMAINS HAS TOISCAT ERNED I ON THE EPROPERTY. RMISSION OF (HEALTH AND SAFETY CODE SECTION 7116.) 11A. NAME AND ADDRESS OF CALIFORNIA CEMETERY It 1 B. DATE BURIED 111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL i BURIAL I j, i DATE CREMATED 112C, SIGNATURE OF PERSON IN CHARGE OF CREMATION LU CREMATION 12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY FAIRMONT MEMORIAL PARK 1901 UNION 112B. I I , (9A�� CO AVE., FAIRFIELD, CA ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS P �Cc 7 1138. DATE RECEIVED { 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY 13A. NAME AND I 1 CL SCIENTIFIC IL USE I� 14A. NAME AND ADDRESS OF RECEIVING STATE OR COUNTRY WHERE14B. DATE SHIPPED 14C' OF PLACING WITH THE CARRIERGNATURE OF IN CHARGE ADDRESS AND REMAINS R CREMATED REMAINS ARE TO BE SHIPPED a TRANSIT BLAIR CEMETERY, BLAIR NE 68008 O ON IN' 15A. O 1158 OF DISPOSITION PREMA REMAINS DIS- DISPOSITION ICFARGE iOSER SCATT SUFFICIENT TO IDENTIFY AND A DISTRICT OF DISPOSITION. - IF APPLICABLE AT SEA OR IF BURIAL AT SEA, ONLY ENTER LATITUDE AND LONGITUDE I 1 DISPOSITION OTHER THAN IN CEMETERY f j► COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION, THE PERSON IN CHARGE OF DISPOSITION IS RESPONSitsLIM FOR COMPLETING AND OR THE DISTRICT EARESTT/HE POINT WHERE ARDING THE ITHE CCIT IREIMAT DN 10 AREMAINS WERE SYS OF CATTERED ATN TO THE G SEA. THE HE LOCALL REGISTRAR MAY DESTROY ANY RIG ORIR OF THE DISTRICT IN WHICH DISPOSITION GINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE, VS9e (REV.12/04) COPY 1 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF VITAL RECORDS SPECIAL INSTRUCTIONS REGARDING CREMATION THE FOLLOWING N OF REMAINS OTHER THAN IN OA CEMETRY ERYANDAPPLICABLENS ARE AND BURIAL ATSEA AFT R CREMATION AS PROVIDED NCREMATED HEALTH AND SAFETY CODE SECTIONS 7054.6, 7116, 7117, AND 103060. NO PERSON SHALL DISPOSE OF OR OFFER TO DISPOSE OF ANY CREMATED HUMAN REMAINS UNLESS REG- ISTERED AS A CREMATED REMAINS DISPOSER BY THE STATE CEMETERY BOARD. THIS ARTICLE SHALL NOT APPLY TO ANY PERSON, PARTNERSHIP, OR CORPORATION HOLDING A CERTIFICATE OF AUTHORITY AS A CEMETERY, CREMATORY LICENSE, CEMETERY BROKER'S LICENSE, CEMETERY SALESMAN'S LICENSE, OR FUNERAL DIRECTOR'S LICENSE, NOR SHALL THIS ARTICLE APPLY TO ANY PERSON HAVING THE RIGHT TO CONTROL THE DISPOSITION OF THE CREMATED REMAINS OF ANY PERSON OR THAT PERSON'S DISIGNEE IF THE PERSON DOES NOT WITHIN ANY CALENDAR YEAR.OSE (BUSSIINEOR OFFER TO DISPOSE S AND PROFESSIONS COO EORE ECTIHAN 10 ON 9740.)EMATED HUMAN REMAINS CREMATED REMAINS MAY BE SCATTERED IN AREAS WHERE NO LOCAL PROHIBITION EXISTS, PROVIDED THAT THE CREMATED REMAINS ARE NOT DISTINGUISHABLE TO THE PUBLIC, ARE NOT INA CONTAINER, AND THAT THE PERSON WHO HAS CONTROL OVER TTEN P THE PRDISPOSOPERTY OWNER ORTION OF THE TGOVERNING AGENCYED REMAINS HAS TOISCAT ERNED I ON THE EPROPERTY. RMISSION OF (HEALTH AND SAFETY CODE SECTION 7116.) APPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS tA. NAME OF DECEDENT — FIRST (GIVEN) MICHAEL USE BLACK INK ONLY - MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS DATE OF BIRTH - JNTH, DAY, YEAR 10/30/1967 LAST (FAMILY) STONER /3 01A DATE OF DEATH 14, SEX )NTH,DAY,YEAR M 6/27/2007 •5B. COUNTY OF DEATH — OUTSIDE CALIF., 6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE 5A. CITY OF DEATH TENTER STATE OF INFORMANT VACAVILLE SOLANO LAN[ STONER, FOSTER MOTHER 7A TYPED NAME AND ADDRESS OF CALIFORNIA—FUNERAL DIRECTOR OR PERSON ACTING AS SUCH (76. CALIIFF. LICENSENUMBER1616 CORTEZ AVE. BRYAN-BRAKER FUNERAL HOME, 1850 W TEXAS ST PO 1 FD988 STOCKTON CA 95209 BOX 7 FAIRFIELD, CA 94533 I 8A. SIGNATURE OF APPLICANT— Person taBng Permit BB.DATESIGNED 106/29/2007 ACKNOWLEDGEMENT OF APPLICANT I hereby acknowledge as applicant that the proposed slated herein is on of the dispositions"authorized by Sectbn 103055 of the Health and Safety Code, and was authorized pursuant to Section 7100 of the Health and Safety Code. THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF 9A. AMOUNT OF FEE PAID 9B. DATE PERMIT ISSUED 9C. SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT /- THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE AUTHOR- C ':': PERMIT ITY NOTE: THIS HPERMTOWEIONSPECIFIED INTHIS PERMIT. DEOFCALIFORNIA $11.00 106/29/2007 1RONALD W CHAPMAN NO RIGHT OF DISPOSAL i U, AUTHORIZATION OF LOCAL REGISTRAR 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH ROEnTN occuaam NcuFoauw 9E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION -- sD�Osniw+ is To MCUR N AuonIR DWRIcT N C—ORNA H IITION REQUERESANEW SOLANO HEALTH DEPARTMENT ! PERMIT TO SHOW FINAL DISPOSITION 355 TUOLUMNE STREET 4 VALLEJO, CA 94590 ; 10. AUTHORIZED DISPOSITION(S) IFOR CREMATION/TRANSIT CORONER'S USE ONLY COPY 3 OF THE PERMIT IS TO BE RETURNED TO THE COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT. IF NOT APPLICABLE, COPY 3 MAY BE DISCARDED. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL DUPLICATE PERMIT AFTER ON YEAR FROM ISSUE DATE. COPY 3 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF VITAL RECORDS VS9e (REVA2104) SPECIAL INSTRUCTIONS REGARDING CREMATION THE REMAINS O HIER THAN IN PROVISIONSTORY N A CEMETEAPPLICABLE Y AND BURIAL AT SEA AFTER CREMATION AS PROVIDED N HEALTH AND SAFETY CODE SECTIONS 7054.6, 7116, 7117, AND 103060. NO PERSON SHALL DISPOSE OF OR OFFER TO DISPOSE ANY CREMATEDREMAINS LESS REG- ISTERED AS A CREMATED REMAINS DISPOSER BY THE STOATE CEMETERY BOARD.ATHIS ARTICLENSHALL NOT APPLY TO ANY PERSON, PARTNERSHIP, OR CORPORATION HOLDING A CERTIFICATE OF AUTHORITY AS A CEMETERY, CREMATORY LICENSE, CEMETERY BROKER'S LICENSE, CEMETERY SALESMAN'S LICENSE, OR FUNERAL DIRECTOR'S LICENSE, NOR SHALL THIS ARTICLE APPLY TO ANY PERSON HAVING THE RIGHT TO CONTROL THE DISPOSITION OF THE CREMATED REMAINS OF ANY PERSON OR THAT PERSON'S DISIGNEE IF THE PERSON DOES NOT WITHIN ANY CALENDAR YEAR. (BUSSE SIINEOSSOFFER AND PROFESSIONS CODEMORE SECT ON 9740.)EMATED HUMAN REMAINS CREMATED REMAINS MAY BE SCATTERED IN AREAS WHERE NO LOCAL PROHIBITION EXISTS, PROVIDED THAT THE CREMATED REMAINS ARE NOT DISTINGUISHABLE TO THE PUBLIC, ARE NOT IN A CONTAINER, AND THAT THE PERSON WHO HAS CONTROL OVER DISPOSITION OF THE THE PROPERTY OWNER ORTGOVERNING AGENCY ED REMAINS HAS BTO (SCAT ER ON THNED WRITTEN E RMISSION F PROPERTY. (HEALTH AND SAFETY CODE SECTION 7116.) 11A. NAME AND ADDRESS OF CALIFORNIA CEMETERY 111 B. DATE BURIED 111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL i BURIAL it3, I i12B. DATE CREMATED i 12C. SIGNATURE OF PERSON IN CHARGE OF CREMATION 12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY LU CREMATION FAIRMONT MEMORIAL PARK 1901 UNION / CA `d�'a�©'�� J AVE., FAIRFIELD, 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY v 13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 1138. DATE RECEIVED i CL SCIENTIFIC t i a. USE 1 D SIGNATURE OF ERSON IN CHARGE 14A. NAME AND ADDRESS OF RECEIVING STATE OR COUNTRY WHERE j148. DATE SHIPPED 14C• ADDRESSOCINGNWITH THE CARRIER REMAINS R CREMATED REMAINS ARE TO BE SHIPPED 4i w a TRANSIT BLAIR CEMETERY, BLAIR NE 68008 i O C) 15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION i158. DATE OF 15C. SIGNATURE OF PERSON IN 116D.LICENSE DISPOSITION CHARGE OF DISPOSITION DSREMAINS DIS- SCATTERINGBURIAL SUFFICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION. i POSER - IF APPLICABLE AT SEA, ONLY ENTER LATITUDE AND LONGITUDE I AT SEA OR DISPOSITION OTHER, THAN IN CEMETERY IF BURIAL ' COPY 3 OF THE PERMIT IS TO BE RETURNED TO THE COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT. IF NOT APPLICABLE, COPY 3 MAY BE DISCARDED. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL DUPLICATE PERMIT AFTER ON YEAR FROM ISSUE DATE. COPY 3 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF VITAL RECORDS VS9e (REVA2104) SPECIAL INSTRUCTIONS REGARDING CREMATION THE REMAINS O HIER THAN IN PROVISIONSTORY N A CEMETEAPPLICABLE Y AND BURIAL AT SEA AFTER CREMATION AS PROVIDED N HEALTH AND SAFETY CODE SECTIONS 7054.6, 7116, 7117, AND 103060. NO PERSON SHALL DISPOSE OF OR OFFER TO DISPOSE ANY CREMATEDREMAINS LESS REG- ISTERED AS A CREMATED REMAINS DISPOSER BY THE STOATE CEMETERY BOARD.ATHIS ARTICLENSHALL NOT APPLY TO ANY PERSON, PARTNERSHIP, OR CORPORATION HOLDING A CERTIFICATE OF AUTHORITY AS A CEMETERY, CREMATORY LICENSE, CEMETERY BROKER'S LICENSE, CEMETERY SALESMAN'S LICENSE, OR FUNERAL DIRECTOR'S LICENSE, NOR SHALL THIS ARTICLE APPLY TO ANY PERSON HAVING THE RIGHT TO CONTROL THE DISPOSITION OF THE CREMATED REMAINS OF ANY PERSON OR THAT PERSON'S DISIGNEE IF THE PERSON DOES NOT WITHIN ANY CALENDAR YEAR. (BUSSE SIINEOSSOFFER AND PROFESSIONS CODEMORE SECT ON 9740.)EMATED HUMAN REMAINS CREMATED REMAINS MAY BE SCATTERED IN AREAS WHERE NO LOCAL PROHIBITION EXISTS, PROVIDED THAT THE CREMATED REMAINS ARE NOT DISTINGUISHABLE TO THE PUBLIC, ARE NOT IN A CONTAINER, AND THAT THE PERSON WHO HAS CONTROL OVER DISPOSITION OF THE THE PROPERTY OWNER ORTGOVERNING AGENCY ED REMAINS HAS BTO (SCAT ER ON THNED WRITTEN E RMISSION F PROPERTY. (HEALTH AND SAFETY CODE SECTION 7116.)