Martha Viola HainTERMIT FOR DISPOSITION OF HUMAN REMAINS
NAME OF DECEDENT SEX DATE OF BIRTH DATE OF DEATH
PIAPTHA VIOLA T-!Aru Female July 31, 1902
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
Ventura I Ventura George E. Flain (171usbany�)
NAME OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH)
FALIFORNIA LICENSE NUMBER 190 ]Srmming
al
Ted M. Mayr FunerHome 1 0
1 667 Ventura 2 CA 93003
TYPE OF PERMIT. CHECK ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
1-] 5. DISINTERMENT AND BURIAL (INCLUDES El 8. DISINTERMENT AND REINTERMENT OF CREMATED
1. BURIAL (INCLUDES ENTOMBMENT) ENTOMBMENT) REMAINS (INCLUDES INURNMENT)
❑ 2. CREMATION AND BURIAL (INCLUDES INURNMENT) El 6. DISINTERMENT, CREMATION, AND BURIAL
❑ 3. CREMATION AND DISPOSITION OTHER THAN IN A (INCLUDES INURNMENT)
CEMETERY
❑ 7. DISINTERMENT, CREMATION, AND DISPOSITION El 9. DISINTERMENT OF CREMATED REMAINS AND
EJ 4. SCIENTIFIC USE OTHER THAN IN A .CEMETERY DISPOSITION OTHER THAN IN A CEMETERY
FOR THE PURPOSE OF ISSUING THIS PERMIT, DISINTERMENT IS DEFINED AS THE REMOVAL OF HUMAN REMAINS FROM ONE SPECIFIED PLACE OF DISPOSITION TO ANOTHER SPECIFIED PLACE
OF DISPOSITION. COMPLETE EACH ITEM REQUIRED FOR THF TYPE OF `FRMIT,;PrriFiPn apnxip ANn imw 1—TT —1. 1 1— 1-T . I— — T
OF BIRTHS AND DEATHS.
OF CALIFORNIA—DEPARTMENT OF HEALTH SERVICES --OFFICE OF THE STATE REGISTRAR
NAME AND ADDRESS OF CEMETERY WHERE, REMAINS: ARE TO BE INTERRED ICOUNTY
BURIAL
Blair Cemeter-y, Blair, NB I llashingt(
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED
DATE CR
SIGNATURE OF PERSON IN CHARGE OF CREMATORY
CREMATION
N11%
N/A
INTERMENT
NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED COUNTY
AFTER
N/A
CREMATION
NIA
BURIAL AT SEA
ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF DISPOSITION
OR
DISPOSITION OTHER
N/A
THAN IN A CEMETERY
OF CREMATED REMAINS
This is to certify that I am the person having the right to control the disposition of the
SIGNATURE OF APPLICANT
ACKNOWLEDGMENT
remains of the above named decedent under provisions of the Health and Safety Code,
N/A
OF
APPLICANT
and I hereby acknowledge that trespass and nuisance laws apply and understand that
DATE SIGNED
this permit gives no right of unrestricted access to property not owned by me.
N/A
SCIENTIFIC
NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
USE
N/A
LOCAL
THIS PERMIT 15 ISSUED IN ACCORDANCE WITH PROVISIONS OF AMOUNT OF FEE PAID -1 DATE PERMIT ISSUED
SIGNATURE OF LOCAL REGISTRA# ISSUING PERMIT
REGISTRAR
THE CALIFORNIA HEALTH AND SAFETY CODE AND 15 THE
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT 2. 00 U"' GJ 4 98146
A, "2"
CERTIFICATION
PERSON IN CHARGE
I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON
SIGNATURE OF PERSON IN CHARGE OF DISPOSITION
qPOSITION
(ENTER DATE)-'
OF BIRTHS AND DEATHS.
OF CALIFORNIA—DEPARTMENT OF HEALTH SERVICES --OFFICE OF THE STATE REGISTRAR