Martha Gustason HewettNAME OF DECEDENT --I—
MARTHA CIUSTASON HEWETT
SEX
DATE OF BIRTHDATE OF DEATH
1
r emiale
PLACE OF DEATH—CITY OR —TOWN F _
PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA)
I
8
M101Jul22
ay ,898 y , 1981
NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
San.Bernardino San Bernardino
NAME OF FUNERAL
Dale Gustason-Son
DIRECTOR (OR PERSON ACTING AS SUCH)
—LICENSE
CALIFORNIA NUMBER
111ark B. Shav G-6mpany, Inc
4051 Ist Avenue
406
San Beraardinoji 92407
TYPE OF PERMIT. CHECK ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
1. BURIAL (INCLUDES ENTOMBMENT) DISINTERMENT AND BURIAL (INCLUDES
ENTOMBMENT)
❑ 8. DISINTERMENT AND REINTERMENT OF CREMATED
02. CREMATION AND BURIAL (INCLUDES INURNMENT)
REMAINS (INCLUDES INURNMENT)
06. DISINTERMENT, CREMATION, AND BURIAL
03. CREMATION AND DISPOSITION OTHER THAN IN A (INCLUDES INURNMENT)
CEMETERY
CREMATION
7. DISINTERMENT, , AND DISPOSITION
114. SCIENTIFIC USE A
El 9. DISINTERMENT OF CREMATED REMAINS AND
OTHER THAN IN A CEMETERY
DISPOSITION OTHER THAN IN A CEMETERY
FOR THE PURPOSE OF ISSUING THIS PERMIT, DISINTERMENT IS DEFINEDAS THE REMOVAL OF HUMAN REMAINS FROM ONE SPECIFIED
OF DISPOSITION. COMPLETE EACH ITEM REQUIRED FOR
PLACE OF DISPOSITION TO ANOTHER SPECIFIED PLACE
PERMIT
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
BURIAL
FOUNTY
TG —1,
NAME AND ADDRESS OF CREMATORYWHERE REMAIN
C M To Y M I S
CREMATION � ARE TO BE CREMATED DATE CREMATED
Jill Ir. -I
SIGNATURE OF PERSON IN CHARGE OF CREMATORY
M T I, Or ... T, ", "'I, A '_ " ",
INTERMENT
NTERMENT NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE IU bit INTERRED
AFTER
17
CREMATION
COUNTY
BURIAL AT SEA AD -----
OR OR OTHER T TO IDENTIFY FINAL PLACE AND `COUNTY -
DISPOSITION OTHER
THAN IN A CEMETERY
OF CREMATED REMAINS
This is to certify that 0 am the person having the right to control the disposition of the
ACKNOWLEDGMENT
SIGNATURE OF APPLICANT
remain, of the above named decedent under Provisions of the Health and Safety Code,
OF
01
APPLICANT and I hereby acknowledge that trespass and nuisance laws apply and understand that
DATE SIGNED
this permit gives no right of unrestricted access to property not owned by me.
SCIFN TiFIC NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
USE
THE CALIFORNIA HEALTH AND SAFETY CODE oND IS THE:
REGISTRAR
LOCAL THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF ]:A:M:O:U:N:
PERMIT
AMOUNT OF D
FEE PAI
PERMIT IS
DATE SUED
SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS
0
CERTIFICATION
OF PERSON IN CHARGE I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON"
SIGNATURE OF PERSON IN CHARGE OF DISI'SITION
OF DISPOSITION
------------------------------------ (ENTER DATE)
(ENTER DATE)
COPY I IS RETAINED BY THE 01 GE PERSON N IN CHARTHE
E G 11 CEMETERY 'WHERE THE "HUMAN -R--EMA-
BY THE PERSON IN CHARGE 01 THE FACILITY WHERE THE REMAINS ARE UTILIZED FOR SCIENTIFI INS ARE INTERRED, OR BY THE PERSON IN CHARGE OF THE CREMATORY WHERE THE REMAINS ARE CREMATED, OR
C USE.
COPY 2 STATE OF CALIFORNIA—DEPARTMENT OF HEALTH SERVICES—OFFICE OF THE STATE REGISTRAR OF VITAL STATISTICS (REV. 5-78) FORM VS -9