Weaver, Robert PERMIT FOR REMOVAL OF CREMATED OR INTERRED HUMAN REMAINS
NAME OF DECEDENT—FIRST NAME (MIDDLE NAME ILAST NAME
DECEDENT ROBERT 1 ADi`U. _ 1 WEAVER
PERSONAL AGE SEX DATE OF DEATH
DATA 18 I Male December 13, 1952
PLACE OF PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY
DEATH Pacific Grove Monterey
NAME OF PERSON APPLYING FOR PERMISSION TO REMOVE REMAINS
APPLICANT Little Chapel by the Sea Crematorium
FROM:ROM:CITY OR TOWN TO:CITY OR TOWN.STATE
DATA Pacific Grove ,CALIFORNIA Glen Falls, New York
RE-INTERMENT NAME OF CEMETERY TO WHICH REMAINS ARE TO BE DELIVERED
DATA Potter Funeral Home for interment in the Ridge Road Quaker Cemetery
LOCAL In accordance with provisions of the Health and Safety Code permission is hereby granted to the applicant named above,for the disinterment and
REGISTRAR removal of the above identified remains,as specified in this permit.
OF
VITAL SIGNATURE OF.LOCAL R ISTRAR VITAL STAT S J (REGISTRATION DISTRICT NUMBER(DATE PERMIT ISSUED
STATISTICS 141
JJ/ ,. ; 'i.j., December 7, 1953
RECEIPT OF 9F PERSON ACKNOWLEDG111G EIPT F R AINS / DATE REMAINS RECEIVED
REMAINS 1SIGNATURE
V* r .(/, t.i
Yf Cn.�r - ,n EE STRUCTIONS ON THE REVERSE OF THIS FORM
REV.7.1.49
;TATE OF CALIFORNIA FORM R&S.9 DEPARTMENT OF PUBLIC HEAL1
INSTRUCTIONS
1. The fee for issuance of this permit is $0.50.
2. Prepare this permit in triplicate.
a. The original accompanies the remains to their destination.
b. The duplicate is retained by the person delivering the remains for removal.
c. The triplicate is filed by the Local Registrar of Vital Statistics who issues the permit.
3. The person who receives the remains at the designated cemetery of delivery must
complete and sign the permit in the spaces provided, and forward the permit to the
Local Registrar of Vital Statistics of the registration district in which the cemetery is
located.
4. This permit DOES NOT authorize the removal of remains not previously interred or
cremated.
44175 5-51 2511 o4,SFU