Zeke Clifford HalsteadZE
PERMIT FOR DISPOSITIONREMAINS
USE BLACK INK—MAKE NO ALTERATIONS OR ERASURES
NAME OF DECEDENT SEX DATE OF BIRTH DATE�DFDEATH
Zeke Clifford Halstead dale March 29, 1911 Aust 24, 1988
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
Porterville I Tulare Mae Halstead - Wife
NAME AND ADDRESS OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) CALIFORNIA LICENSE NUMBER 19802 Ave. 164
Byers Funeral Service & Crematory - Porterville CA 713 L—LPorterville CA 93257
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
ENTOMBMENT) REMAINS (INCLUDES INURNMENT)
ZI Z. CREMATION AND BURIAL (INCLUDES INURNMENT)
❑ 6. DISINTERMENT, CREMATION, AND BURIAL ❑ 9. DISINTERMENT OF CREMATED REMAINS AND
(INCLUDES ..INURNMENT) D!SPOSITION OTHER THAN IN A CEMETERY
❑ 3. CREMATION AND DISPOSITION OTHER THAN IN A
CEMETERY ❑ 7. DISINTERMENT, CREMATION, AND DISPOSITION FOR CORONER'S USE ONLY
❑ 4. SCIENTIFIC USE OTHER THAN IN A CEMETERY
❑ 10. DISPOSITION PENDING
INTERMENT
NAME AND ADDRESS OF CEMETERY WHERE REMAINS OR CREMATED REMAINS ARE TO BE INTERRED COUNTY
Blair Cemetery - Blair, Nebraska
' lea sh i gon
CREMATION
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED
DATE CREMATED
SIGNA OF PERSON IN HA OF CREMATORY
Myers Funeral Service & Crematory - Porterville, CA
08-26-1988
BURIAL R SEA
OR
ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PL E AND COUNTY OF DISPOSITION
DISPOSITION OTHER
THAN IN A CEMETERY
OF CREMATED REMAINS
SCIENTIFIC
NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
USE
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 sender provisions of the Health and Safety Code,
� � /
OF
APPLICANT
and I hereby acknowledge that trespass and nuisance laws apply and understand that
_
DATE
this permit gives no right of unrestricted access to property not owned by me.
SIGNED
A'u ust 25 1988
LOCAL
REGISTRAR
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS AMOUNT F FEE PAID DATE PERMIT ISSUED
OF THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE p U
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT G 2 6 1988
SIGNATUR OF {.O AL REG RAR ISSUING PERMPr
t
CERTIFICATION
OF PERSON IN CHARGE
I CERTIFY THAT THE SPECIFIED SIGNATURE OF PERSON IN CHARGE OF DISPOSITION LICENSE NUMBER OF CREMATED REMAINS
DISPOSITION WAS MADE ON
OF DISPOSITION I
(ENTER DATE)
Inlnlr ATG —1-1 —
DISPOSER, IF APPLICABLE
IF DISPOSITION IS
TO OCCUR IN
ANOTHER COUNTY Tulare County Health Dept.- Hillman Health Center- 1062 S. I'KII St.- Tulare, CA 93274
COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION. THE PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR
COMPLETING THE PERMIT AND FORWARDING THE COMPLETED PERMIT WITHIN 10 DAYS OF DISPOSITION TO THE REGISTRAR OF THE DISTRICT IN WHICH DISPOSI-
TION OCCURRED OR THE DISTRICT NEAREST THE POINT WHERE THE CREMATED REMAINS WERE BURIED AT SEA. THE LOCAL REGISTRAR MAY DESTROY ANY
ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR.
COPY 1 STATE OF CALIFORNIA—DEPARTMENT OF HEALTH SERVICES—OFFICE OF STATE REGISTRAR OF VITAL STATISTICS (REV. 1-86) FORM VS -9