Stiles, John THIS PACKAGE
CONTAINS THE CREMATED REMAINS OF
JOHN STANLEY STILES
from
LAKEWOOD MEMORIAL PARK
MODESTO, CALIFORNIA
7/3/75 #2711-C
.. ''� 1 O 2 PERMIT FOR DISPOSITION OF HUMAN REMAINS
124 PERMIT NUMBER
NAME OF DECEDENT DATE OF BIRTH DATE OF DEATH
John Stanley Stiles March 5, 1884 June 27 , 1975
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
Sonora Tuolumne Ethel Stiles
NAME OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) 1 CALIFORNIA LICENSE NUMBER 236 Sylvan Drive
Terzich & Wilson-Sonora, California 1 762 Sonora, California
TYPE OF PERMIT. CIRCLE ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
1. BURIAL (INCLUDES ENTOMBMENT) 6. DISINTERMENT AND BURIAL (INCLUDES ENTOMBMENT) 10. DISINTERMENT AND REINTERMENT OF CREMATED REMAINS
r. CREMATION AND BURIAL (INCLUDES INURNMENT) (INCLUDES INURNMENT)
7. DISINTERMENT. CREMATION, AND BURIAL
3. CREMATION AND BURIAL AT SEA (INCLUDES INURNMENT)
II. 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 EACH ITEM REQUIRED FOR THE TYPE OF PERMIT SPECIFIED ABOVE AND ENTER "NOT APPLICABLE" IN EACH LINE NOT REQUIRED FOR THE SPECIFIED DISPOSITION.
NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED COUNTY
BURIAL
Na
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED DATE CREMATED SIGNA F PERSON IN CHAR 0 CREMATORY
CREMATION
w — , re al 1 5[i ' ► jr,
INTERMENT NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED I COUNTY
AFTER 1
CREMATION Pine View Cemeter -Glens Falls New York
BURIAL AT B•` " I.RCRAFT BURIAL AT SEA NAME OF NEAREST POINT ON SHORELINE I COUNTY
SEA AFTER NOT LESS THAN
.,CREMATION -:EE MILES FROM:
DISPOSITION OUTSIDE DESCRIPTION AND ADDRESS SUF - • IDENTIFY FINAL PLACE OF DISPOSITION 'Y
CORPORATE CITY _ I
LIMITS,AND OTHER _ I
THAN IN A CEMETERY THIS IS TO CERTIFY THAT I AM THE PERSON HAVING THE RIGHT ••11 ION OF THE SIGNATURE OF APPLICANT
AS PROVIDED IN
HEALTH AND SAFETY ACKNOWLEDGMENT REMAINS OF THE ABOVE NAMED DECEDENT UNDER PROVISIONS OF - • AND SAF _ • SECTION '
CODE OF
SECTIONS 7054.6
APPLICANT 7100. AND I HEREBY ACKNOWLEDGE THAT THE •• •.NUISANCE LAWS APPLY AND UNDERSTAND THA SIGNED
AND 10376(C). THIS PERMIT GIVES NO RIGHT•.: . STRICTED ACCESS TO PROPERTY NOT OWNED BY ME.SCIENTIFIC NAME AND ADDRESS•-. •
USE
THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF THE CALIFORNIA AMOUNT OF FEE PAID DATE PERMIT ISSUED SIGNATURE OF LOCAL REGISTRAR ISSUING PER T
HEALTH AND SAFETY CODE AND IS THE AUTHORITY FOR THE DISPOSITION Iy�` _ �T ']� {/D�
SPECIFIED IN THIS PERMIT -!2 00 -1- , .L ERT H• UVELLI • 2-I/'f _ ,_,
_ 71— SIGNATI •` ` t''• Ny��+ 'Y OR OTHER DISPOSITION
I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON • '5 /,, , I
.(ENTER DATE) T ' LMillligdirigt
COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION. THE PERSON IN CHARGE OF D:•OSITION IS R •ONSIBLE FOR COMPLETING THE PERMIT AND FORWARDING THE COM.
PLETED PERMIT WITHIN 10 DAYS TO THE LOCAL REGISTRAR OF THE DISTRICT IN WHICH DISPOSITION OCCURRED OR TO Tay LOCAL REGISTRA'. OF THE DISTRICT NEAREST THE POINT WHERE THE CREMATED RE-
MAINS WERE BURIED AT SEA.
COPY 1 STATE OF CALIFORNIA—DEPARTMENT OF HEALTH—OFFICE OF THE STATEOF VITAL STATISTICS (REV. 7-1-73) FORM VS-9