Ramsey, John MIIIIIIIII
4 4 9 4 PERMIT FOR DISPOSITION OF HUMAN EMAINS
PERMIT NUMBER
AME OF DECEDENT DATE OF BIRTH DATE OF DEATH
JOHN: H. RAMSEY Nov. 1, 1931 6-11-1973
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
Los Angeles Los Angeles
NAME OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) CALIFORNIA LICENSE NUMBER Harold Ramsey
Potter Funeral Home/Glens Falls, N•Y. 1 None ale rAv euY.
Fans,
N.
TYPE OF PERMIT. CIRCLE ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
l 1. BURIAL (INCLUDES ENTOMMENTB ) 6- DISINTERMENT AND BURIAL (INCLUDES ENTOMBMENT) 10. DISINTERMENT AND REINTERMENT OF CREMATED REMAINS
�swn ���� (INCLUDES INURNMENT)
2. CREMATION AND BURIAL (INCLUDES INURNMENT) 7. DISINTERMENT.CREMATION,AND BURIAL
3, CREMATION AND BURIAL AT SEA (INCLUDES INURNMENT)
11. DISINTERMENT OF CREMATED REMAINS AND BURIAL AT SEA
4. CREMATION AND DISPOSITION OUTSIDE CORPORATE CITY 8. DISINTERMENT. CREMATION AND DISPOSITION OUTSIDE
LIMITS.AND OTHER THAN IN A CEMETERY. AS PROVIDED CORPORATE CITY LIMITS.AND OTHER THAN IN A
IN HEALTH AND SAFETY CODE SECTIONS 7054.6 AND CEMETERY. AS PROVIDED IN HEALTH AND SAFETY CODE 12. DISINTERMENT OF CREMATED REMAINS AND DISPOSITION
10376(C). SECTIONS 7054.6 AND 10376(C). OUTSIDE CORPORATE CITY LIMITS. AND OTHER THAN IN
A CEMETERY. AS PROVIDED IN HEALTH AND SAFETY CODE
5. SCIENTIFIC USE 9. DISINTERMENT.CREMATION,AND BURIAL AT SEA SECTIONS 7054.6 AND 10376(C).
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 EAACHH ITEM REQUIRED FOR THE TYPE OF PERMIT SPECIFIED ABOVE AND ENTER"NOT APPLICABLE" IN EACH LINE NOT REQUIRED FOR THE SPECIFIED DISPOSITION.
NAIOND I SS OF_CEMETERY WHERE REMAINS ARE TO BE INTERRED COUNTY
BURIAL ( VVV_��''C�s�I-s Cemetery/Glens Falls, N.Y. Warren
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED DATE CREMATED SIGNATURE OF PERSON IN CHARGE OF CREMATORY
CREMATION n/a
INTERMENT NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED COUNTY
AFTER CREMATION n/a
BURIAL AT BOAT OR AIRCRAFT BURIAL AT SEA NAME OF NEAREST POINT ON SHORELINE COUNTY
SEA AFTERI` NOT LESS THAN
-CREMATION a7 a THREE MILES FROM: -
DISPOSITION OUTSIDE DESCRIPTION AND ADDRESS SUFFICIENT TO IDENTIFY FINAL PLACE OF DISPOSITION COUNTY
CORPORATE CITY n/a
LIMITS.AND OTHER
THAN IN A CEMETERY THIS IS TO CERTIFY THAT I AM THE PERSON HAVING THE RIGHT TO CONTROL THE DISPOSITION OF THE SIGNATURE OF APPLICANT
AS PROVIDED IN ,
HEALTH AND SAFETY ACKNOWLEDGMENT REMAINS OF THE ABOVE NAMED DECEDENT UNDER PROVISIONS OF HEALTH AND SAFETY CODE SECTION
CODE OF
SECTIONS 7054.E
APPLICANT 7100, AND I HEREBY ACKNOWLEDGE THAT TRESPASS AND NUISANCE LAWS APPLY AND UNDERSTAND THAT DATE SIGNED
AND 10376(C). THIS PERMIT GIVES NO RIGHT OF UNRESTRICTED ACCESS TO PROPERTY NOT OWNED BY ME.
SCIENTIFIC NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
USE n/a
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF THE CALIFORNIA AMOUNT OF FEE PAID DATE PERMIT ISSUED A•TURE OF LOCAL RNS AR ISS ING P•ERMIT
HEALTH AND SAFETY CODE AND IS THE AUTHORITY FOR THE DISPOSITION
SPECIFIED IN THIS PERMIT I
/.7 SIG ATURE 0 PERSON IN CHARGE OF CEM RX- ITION
I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON __._ K . __4 / �,
r t
' ,�
(E TER DAtE) `` (. ; i- e ... _- ,-- - .._..-_--
COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STAB£D PLACE OF DI OSITION. THE PERSON IN CHARGE OF DISPOSIT RESPONSIBLE FOR COMPLETING THE PERMIT AND FORWARDING THE COM-
PLETED PERMIT WITHIN 10 DAYS TO THE LOCAL REGISTRAR OF THE DISTRICT IN ICH DISPOSITION OCCURRED OR TO THE LOCAL REG TRAR OF THE DISTRICT NEAREST THE POINT WHERE THE CREMATED RE-
MAINS WERE BURIED AT SEA, - -
COPY 1 STATE OF CALIFORNIA—DEPARTMENT OF PUBLIC HEALTH— EAU OF VITAL STATISTICS (REV,4.1-73) FORM VS-9