Calvin W ColePERMIT FOR DISPOSITION I.
SEX DATE OF BIRTH DATE OF DEATH
NAME OF DECEDENT
Calvin W. Cole Vital June 6 � 1901 December 22 190
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
Loma Linda San 0�rnardin Virginia Rogers -Daughter
NAME OF FUNERAL DIRECTOR (OR PERSON ACTING As SUCH)
I CALIFORNIA LICENSE NUMBER 2462 W. Ri a g (to Ave.
Allen-McNearney Rialto Funeral Home F 506 San Bernardino, CA 92410
TYPE OF PERMIT. CHECK ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
❑ 5. DISINTERMENT AND BURIAL (INCLUDES ❑ 8. DISINTERMENT AND REINTERMENT OF CREMATED
fit. BURIAL (INCLUDES ENTOMBMENT)
ENTOMBMENT) REMAINS (INCLUDES INURNMENT)
❑ 2. CREMATION AND BURIAL (INCLUDES INURNMENT) ❑ 6. DISINTERMENT, CREMATION, AND BURIAL
❑ 3. CREMATION AND DISPOSITION OTHER THAN IN A
(INCLUDES INURNMENT)
CEMETERY ❑ 7, DISINTERMENT. CREMATION. AND DISPOSITION EJ 9. DISINTERMENT OF CREMATED REMAINS AND
El 4. SCIENTIFIC USE
OTHER THAN IN A CEMETERY DISPOSITION OTHER THAN IN A CEMETERY
FOR THE PURPOSE OF ISSUING THIS PERMIT, DISINTERMENT IS DEFINED AS THE REMOVAL OF HUMAN REMAINS FROM ONE SPECIFIED PLACE OF DISPOSITION TO ANOTHER SPECIFIED PLACE
OF DISPOSITION. COMPLETE EACH ITEM REQUIRED FOR THE TYPE OF PERMIT SPECIFIED ABOVE AND INVALIDATE EACH LINE NOT REQUIRED FOR THE SPECIFIED DISPOSITION.
NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED I COUNTY
I
BURIAL I
NAME AND ADDRESS OF CREM TORY WHERE REMAINS ARE TO BE CREMATED DATE CREjMATED SIGNATURE OF PERSON IN CHARGE CREMATORY
CREMATION 4,A` C11 IP. NA
INTERMENT NAME AND ADDRESS
AFTER
CREMATION
BURIAL AT SEA ADDRESS, NEAREST
OR
DISPOSITION OTHER
THAN IN A CEMETERY
ETERY WHERE REMAINS ARE TO BE INTERRED
(COUNTY
NA NA
ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF
NA
OF CREMATED REMAINS SIGNATURE OF APPLICANT
This is to certify that I am the person having the right to control the disposition of the NA
ACKNOWLEDGMENT remains of the alcove na med decedent under provisions of the health and Safety Code,
110LI and I hereby acknowledge that trespass and nuisance laws apply and understand that DATE SIGNED
APPLICANT �y
this permit gives no right of unrestricted access to property not owned by me. i`eA
SCIENTIFIC NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
USE
LOCAL THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF AMOUNT OF FEE PAID DATE PERMIT ISSUED SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
REGISTRAR THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE (§(' p 9C
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT 00 4 "�" 23,1_s2'
CERTIFICATION / SIGN' URE OF .PERSON IN CHARGE OF DISPOSITION
OF PERSON IN CHARGE I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON /J�'^�ir' - F�
(ENTER DATE)
OF DISPOSITION
HUMAN REMAINS ARE INTERRED, OR BY THEPERSONIN CHARGE OF THE CREMATORY WHERE THE REMAINS ARE CREMATED, OR
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY WHERE THE
BY THE PERSON IN CHARGE OF THE FACILITY WHERE THE REMAINS ARE UTILIZED FOR SCIENTIFIC USE.
COPY 2 STATE OF CALIFORNIA—DEPARTMENT OF HEALTH SERVICES—OFFICE OF THE STATE REGISTRAR OF VITAL STATISTICS
(REV. 5-78) FORM VS -9