Thomas Elbra DonaldsonUSE BLACK INK ONLY -MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS
1A. NAME OF DECEDENT -FIRST (GIVEN) 1B. MIDDLE 1C. LAST (FAMILY)
5A. CITY OF DEATH 15B. COUNTY OF DEATH -OUTSIDE CALIFORNIA, ENTER STATE
1- Ban LnwT im
7A. TYPED NAME AND ADDRESS OF APPLICANT -FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 7B. CALIFORNIA LICENSE P
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weI -IF API,I ABLE
ACKNOWLEDGMENT I hereby acknowledge as applicant that the proposed disposition stated herein is one 8A. SIGNATURE OF APPLIC
OF of the dispositions authorized by Section 10376 of the Health and Safety Code, and
APPI Ir:ANT was authorized oursuant to Section 7100 of the Health and Safetv Code. 10.
2. DATE OF BIRTH 3. DATE OF DEATH 4. SEX
MONTH, DACYt ,YEAR MONTH,,,DAYY YEAR
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6. NAME, RELATIONSHIP, MAILING ADDRESS AND ZIP CODE
OF INFWMJoym F. T ,
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Funeral Director or Person Acting as Such 8B, DATE SIGNEI
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THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI- 9A. AMOUNT OF FEE PAID 9B. DATE PERMIT ISSUED 9C SIGNATURE OF LOCAL REGISTRAR ISSUING
PERMIT SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODE
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED
AUTHORIZATION OF IN THIS PERMIT. n ;;)
LOCAL REGISTRAR NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA
9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH -
ANY CHANGE IN DISPOSI IF DEATH OCCURRED IN CALIFORNIA
TION REQUIRES A NEW ,.;t.a ,,t y vc` A...:_.,
PERMITTOSHOW FINAL a �`�-���* `*� " ^.
DISPOSITION.
10 TYPE OF DISPOSITION(S) AUTHORIZED CHECK ALL APPLICABLE ITEMS
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❑ A. BURIAL (INCLUDES ENTOMBMENT)
0 B. CREMATION
❑ C. DISPOSITION OF CREMATED REMAINS OTHER
THAN IN A CEMETERY
11A. NAME AND ADDRESS OF CEMETERY
INTERMENT I K/
12A. NAME AND ADDRESS OF CREMATORY
CREMATION in
9E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION -
IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
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❑ D. SCIENTIFIC USE
❑ E. TEMPORARY ENVAULTMENT
❑ F. DISINTERMENT
13A. NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
SCIENTIFIC
USE ti/A
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE
REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED
TRANSIT
❑ G, -SHIP IN TO CALIFORNIA
. TRANSIT TO OUTSIDE OF CALIFORNIA
❑ I. DISPOSITION PENDING
1118. DATE INTERREDI 11C. SIGNATURE OF PERSON IN CHARGE OF INTERMENT
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12B. DATE CREMATED i 12C. SIGNATURE OF PERSON IN GHAHGE OF GHEMANUN
13B. DATE RECEIVED 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
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14B. DATE SHIPPED 14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
I I OF= TRANSIT
SCATTERING AT SEA 15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION 15B. DATE OF 15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER
SUFFICIENT TO IDENTIFY FINAL PLACE AND DISTRICT OF DISPOSITION DISPOSITION CHARGE OF DISPOSITION OF CREMATED RE -
OR MAINS DISPOSER
DISPOSITION OTHER -IF APPLICABLE
THAN IN A CEMETERY N
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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 OF DUPLICATE PERMIT AFTER ONE YEAR FROM
ISSUE DATE.
COPY 3 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS (REV. 5/89)
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