Warren Robert BallerUSE BLACK INK—MAKE NO ALTERATIONS OR ERASURES
NAME OF DECEDENT SEX DATE OF BIRTH DATE OF DEATH
WARREN ROBERT BALLER � Hale 6/19/1990 11/25/1952
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
La JollaSats Diego Dorothy egsen Bae r , Wifa
NAME AND ADDRESS OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) CALIFORNIA LICENSE NUMBER 325 Keqptrn St. Apt. 662,
Feat'n't-1-inclill Mortuary 1083 U-1 1— ra rlD�n77
TYPE
2,
TYPE OF PERMIT,
CHECK ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
1. BURIAL (INCLUDES ENTOMBMENT)
❑
5. DISINTERMENT AND BURIAL (INCLUDES
❑ 8. DISINTERMENT AND REINTERMENT OF CREMATED
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED
ENTOMBMENT)
REMAINS (INCLUDES INURNMENT)
❑ 2. CREMATION AND BURIAL (INCLUDES INURNMENT)
/_
❑
6. DISINTERMENT, CREMATION, AND BURIAL
❑ 9. DISINTERMENT OF CREMATED REMAINS AND
BURIAL AT SEA
ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF DISPOSITION
(INCLUDES INURNMENT)
DISPOSITION OTHER THAN IN A CEMETERY
❑ 3. CREMATION AND DISPOSITION OTHER THAN IN A
:t:/
THAN IN A CEMETERY
CEMETERY
❑
7. DISINTERMENT, CREMATION, AND DISPOSITION
FOR CORONER'S USE ONLY
❑ 4. SCIENTIFIC USE
n/
OTHER THAN IN A CEMETERY
❑ 10. DISPOSITION PENDING
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY WHERE THE HUMAN REMAINS ARE INTERRED, OR BY THE PERSON IN CHARGE OF THE
CREMATORY WHERE THE REMAINS ARE CREMATED, OR BY THE PERSON IN CHARGE OF THE FACILITY WHERE THE REMAINS ARE UTILIZED 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 STATE REGISTRAR OF VITAL STATISTICS (REV. 1-86) FORM VS -9
NAME AND ADDRESS OF CEMETERY WHERE REMAINS OR CREMATED REMAINS ARE TO BE INTERRED COUNTY
INTERMENT
Blair Cemetery, Blair, Nebraska I Washington
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED
DATE CREMATED
SIGNATURE OF PERSON IN CHARGE OF CREMATORY
CREMATION
/_
111
BURIAL AT SEA
ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF DISPOSITION
OR
DISPOSITION OTHER
:t:/
THAN IN A CEMETERY
OF CREMATED REMAINS
SCIENTIFIC
NAME. AND ADDRESS OF FACILITY RECEIVING REMAINS
USE
n/
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,
DATE SIGNED
OF
and I hereby acknowledge that trespass and nuisance laws apply and understand that
APPLICANT
this permit gives no right of unrestricted access to property not owned by me.
LOCAL
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS
AMOUNT OF FEE PAID
DATE PERMIT ISSUED
SIG T RE 0 LZISTRAR ISSUINGfEERMIT
OF THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE.
.
REGISTRAR
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT
U�
CERTIFICATION
I CERTIFY THAT THE SPECIFIED
SIGNATURE OF PERSON IN CHARGE OF DISPOSITION
LICENSE NUMBER OF CREMATED REMAINS
OF PERSON IN CHARGE
DISPOSITION WAS MADE ON
DISPOSER, IF APPLICABLE
OF DISPOSITION
(ENTER DATE)
INDICATE ADDRESS OF REGISTRAR OF COUNTY OF DEATH
IF DISPOSITION IS
IN
$1 s0, °sue x '405220 San Diego, CA 32"�.`13
ANOOTHOERCUR
COUNTY
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY WHERE THE HUMAN REMAINS ARE INTERRED, OR BY THE PERSON IN CHARGE OF THE
CREMATORY WHERE THE REMAINS ARE CREMATED, OR BY THE PERSON IN CHARGE OF THE FACILITY WHERE THE REMAINS ARE UTILIZED 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 STATE REGISTRAR OF VITAL STATISTICS (REV. 1-86) FORM VS -9