Beatrice Florala MooreAPPLICATION IT FOR
USE BLACK INK ONLY -MAKE NO ERASL
1A. NAME OF DECEDENT -FIRST (GIVEN) 11B. MIDDLE I 1C. LAST (
Beatrice I Floral �41joori
1 ITION__OF_,HUMAN REMAINS
HITEOUTS OR OTHER ALTERATIONS
rlf I2. DATE OF
MONTH. DAY.
YEAR
3. DATE OF DEATH 14. SEX
MONTH, DAY, YEAR
a slitI as a U I �":7)
5A CITY OF DEATH 15B. COUNTY OF DEATH -OUTSIDE CALIF., 6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
Lodi
I ENTER STATE OF INFORMANT
E.. St San Joaquin Barbara Stoner -Daughter
7A. TYPED NAME AND ADDRESS OF CALIFORNIA -FUNERAL DIRECTOR OR PERSON ACTING AS SUCH: 7B. CALIF. LICENSE NUMBER,
-IF APPLICABLE
tez
Ben Sas Funeral Moms, 149 4th S., 3,C 1 125 Stockton
8A SIGNATURE OF APPLICANT -Person taking permit, 8B. DATE SIGNED
ACKNOWLEDGMENT OF APPLICANT I hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized byMEMEMEW ®,?
Section 10376 of the Health and Safe Code and was authorized ursuant to Section 7100 of the Health and Safety
afe Code. ''
PERMIT 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 I I
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED I
AUTHORIZATION OF N THIS PERMIT. ® '11/19/1993 1 f 1 / I v
ndleman
LOCAL REGISTRAR NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA. j ,5 t?
AUTH, #38557
ANY CHANGE IN DISPOSI 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- 19E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION -
TION REQUIRES A NEW IF DEATH OCCURRED IN CALIFORNIA IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
PERMIT TO SHOW FINAL - -
DISPOSITION. Box 20001 S t A I
P.O.i I
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE ITEMS FOR CORONER'S USE ONLY
EIA. BURIAL (INCLUDES ENTOMBMENT) C E. TEMPORARY ENVAULTMENT F] I. DISPOSITION PENDING -REMAINS LOCATED AT
B. CREMATION F. DISINTERMENT (Name and Address)
O -C. 'DISPOSITION OF CREMATED REMAINS OTHER [71 G. SHIP INCALIFORNIA
TO CALIF
THAN IN A CEMETERY F.
D. SCIENTIFIC USE H. TRANSIT TO OUTSIDE OF CALIFORNIA
11A. NAME AND ADDRESS OF CALIFORNIA CEMETERY 11B. DATE BURIED 111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL I,
BURIAL
I
'76
1 ITION__OF_,HUMAN REMAINS
HITEOUTS OR OTHER ALTERATIONS
rlf I2. DATE OF
MONTH. DAY.
YEAR
3. DATE OF DEATH 14. SEX
MONTH, DAY, YEAR
a slitI as a U I �":7)
5A CITY OF DEATH 15B. COUNTY OF DEATH -OUTSIDE CALIF., 6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
Lodi
I ENTER STATE OF INFORMANT
E.. St San Joaquin Barbara Stoner -Daughter
7A. TYPED NAME AND ADDRESS OF CALIFORNIA -FUNERAL DIRECTOR OR PERSON ACTING AS SUCH: 7B. CALIF. LICENSE NUMBER,
-IF APPLICABLE
tez
Ben Sas Funeral Moms, 149 4th S., 3,C 1 125 Stockton
8A SIGNATURE OF APPLICANT -Person taking permit, 8B. DATE SIGNED
ACKNOWLEDGMENT OF APPLICANT I hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized byMEMEMEW ®,?
Section 10376 of the Health and Safe Code and was authorized ursuant to Section 7100 of the Health and Safety
afe Code. ''
PERMIT 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 I I
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED I
AUTHORIZATION OF N THIS PERMIT. ® '11/19/1993 1 f 1 / I v
ndleman
LOCAL REGISTRAR NOTE: THIS PERMIT GIVES NO RIGHT OF DISPOSAL OUTSIDE OF CALIFORNIA. j ,5 t?
AUTH, #38557
ANY CHANGE IN DISPOSI 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- 19E. ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION -
TION REQUIRES A NEW IF DEATH OCCURRED IN CALIFORNIA IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
PERMIT TO SHOW FINAL - -
DISPOSITION. Box 20001 S t A I
P.O.i I
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE ITEMS FOR CORONER'S USE ONLY
EIA. BURIAL (INCLUDES ENTOMBMENT) C E. TEMPORARY ENVAULTMENT F] I. DISPOSITION PENDING -REMAINS LOCATED AT
B. CREMATION F. DISINTERMENT (Name and Address)
O -C. 'DISPOSITION OF CREMATED REMAINS OTHER [71 G. SHIP INCALIFORNIA
TO CALIF
THAN IN A CEMETERY F.
D. SCIENTIFIC USE H. TRANSIT TO OUTSIDE OF CALIFORNIA
11A. NAME AND ADDRESS OF CALIFORNIA CEMETERY 11B. DATE BURIED 111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL I,
BURIAL
I
I
LU
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY 12B. DATE CREMATED' 12C. SIGNATURE OF PERSON IN CHARGE OF CREMATION
LU
W
CREMATION
'
I I
m
U
I
I I
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 13B. DATE RECEIVED' 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
a
SCIENTIFIC
USE
¢
I -
LU
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE 14B. DATE SHIPPED 14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
W
REMAINSORCREMATED REMAINS ARE TO BE SHIPPED I OF PLACING WITH THE CARRIER
2
TRANSIT
mpb i t ^° r) Funeral HomeI I
0
444 Sia 17th St, Blair,
SCATTERING AT SEA
15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUF- 15B. BATE OF 15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER
OR
FICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION DISPOSITION CHARGE OF DISPOSITION I OF CREMATED RE -
DISPOSITION OTHER
I I MAINS DISPOSER
THAN IN A CEMETERY
I I I -IF APPLICABLE
I
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 STATE REGISTRAR VS9 (REV.6/91)