Barbara Louise StonerAPPLICATION IT FOR DISPOSITIONF HUMAN REMAINS
USE BLACK INK ONLY - MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS
1A. NAME OF F DECEDENT -FIRST (GIVEN) 1 B. MIDDLE ; 1 C. LAST (FAMILY) 2. DATE OF BIRTH 3. DATE OF DEATH 4. SEX
Barbara Louise
Stoner T Y T
5A. CITY OF DEATH ;513. COUNTY OF DEATH - OUTSIDE CALIF., 6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP COE
ENTER STATE F QRMAN
Stockton San Joaquin i � a stoner Jr -husband
7A. TYPED NAMEAND ADDRESS OFCALIFORNIA- FUNERAL DIRECTOR OR PERSONACTING AS SUCH; 7B. CALIF. LICENSE NUMBER1616 Cortez Avenue
- IFAPPLICABLE
ER EE 1-41EMORIAL FUNERAL WME PO Box 1001D IStocktom. CA 95209
Lodi, CA 1 FD 8 SIG ATUR FAPPLICANT- For- pongPe t 8B D T SG
I hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized by Section 103055
ACKNOWLEDGEMENT OF APPLICANT of the Health and Safety Code. and was autho zed oursuant t Section 7100 of the Health and Safer, Code. "�./
PERMIT
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF
9A. AM11.O��F�q FEE PAID
9B. DATE PERMIYTSSUEff 9C. SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
K. hansen
THE CALIFORNIA HEALTH AND SAFETY CODEAND ISTHEAUTHOR-
1.8s iii
-
ITY FOR THE DISPOSITION SPECIFIED IN THIS PERMITAUTHO
08/04/2006f
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FAX i 6 5 i i i
# 41642
LOCALR REGISTRAZATION R
LOCAL REGISTRAR
NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- 19E. ADDRESS
OF REGISTRAR OF DISTRICT
OF DISPOSITION -
ANY CHANGE IN DISPOSI-
IF DEATH OCCURRED IN CALIFORNIA IF DISPOSITION
IS TO OCCUR IN ANOTHER
DISTRICT IN CALIFORNIA
TION REQUIRESA NEW
PERMITTO SHOW FINAL
DISPOSITION
5s it%
PO 1`•.g� 2009 Stock A. 95201
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10. AUTHORIZED DISPOSITION(S) CHECKAPPLICABLE ITEMS
FOR CORONER'S USE ONLY
❑ A. BURIAL (INCLUDES ENTOMBMENT) ❑ E. TEMPORARY ENVAULTMENT
❑ I. DISPOSITION PENDING - REMAINS LOCATED AT
B. CREMATION
❑ F. DISINTERMENT
(Name and Address)
C. DISPOSITION OF
CREMATED REMAINS OTHER ❑ G. SHIP IN TO CALIFORNIA
THAN INA CEMETERY
FID. SCIENTIFIC USE
1XI H. TRANSIT TO OUTSIDE OF CALIFORNIA
11A. NAME AND ADDRESS OF CALIFORNIA CEMETERY
111 B. DATE BURIED 11C. SIGNATURE OF PERSON IN CHARGE OF BURIAL
BURIAL
on
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
;128. DATE CREMATED:
12C. SIGNATURE OF PERSON CHARGE OF CREMATION
Ld
F CREMATION
L-1
m
v
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS
:138. DATE RECEIVED
13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
J
a SCIENTIFIC
USE
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE
:14B. DATE SHIPPED
14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
TRANSIT
REMAIN CREMATED REMAINS RETgO BE SHTP
R ® t '1 S. 7th
Campsie
OF PLACING WITH THE CARRIER
7.
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i$q
I
Street Blair, NE 68008
15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION
:15B. DATE OF
15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER OF
SCATTERING/BURIAL
SUFFICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION
DISPOSITION
CHARGE OF DISPOSITION CREMATED REMAINS DIS -
AT SEA OR
IF BURIAL AT SEA, ONLY ENTER LATITUDE AND LONGITUDE
POSER- IFAPPLICABLE
DISPOSITION OTHER
THAN INA CEMETERY
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY, CREMATORY, FACILITY FOR SCIENTIFIC USE, OR BY THE PERSON IN CHARGE OF
DISPOSING OF THE CREMATED REMAINS.
COPY 2 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF VITAL RECORDS VS -9 (REV. 6/04)