Roberts, John G 41089 PERMIT FOR DISPOSITION OF HUMAN REMAINS
PERMIT NUMBER
NAME OF DECEDENT DATE OF BIRTH DATE OF DEATH
John C Roberts June 19 1906 July 9 1976
PLACE OF DEATH-CITY OR TOWN PLACE OF DEATH-COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
Hayward Alameda Lucinda Roberts
NAME OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) 1 CALIFORNIA LICENSE NUMBER P.O.BOX 186
Santos-Robinson Mortuary San Leandro i F-81 Summerland Calif 93867
TYPE OF PERMIT. CIRCLE ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
I. BURIAL (INCLUDES ENTOMBMENT) 6. DISINTERMENT AND BURIAL (INCLUDES ENTOMBMENT) 10. DISINTERMENT AND REINTERMENT OF CREMATED REMAINS
(INCLUDES INURNMENT)
2. CREMATION AND BURIAL (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 N/A Alameda
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED DATE CREMATED SIGNATURE OF PERSON IN CHARGE OF CREMATORY
CREMATION
Cedar lawn Cenetery Fremont E
INTERMENT NAME AND ADDRESS OF CEMETERY WHERE R MAINS ARE TO
BE INTERREDCOUNTY
AFTER � 7YJ"`
CREMATION
BURIAL AT BOAT OR AIRCRAFT BURIAL AT SEA NAME 0 AREST POINT ON SHORELINE ti COUNTY
SEA AFTER NOT LESS THAN
CREMATION 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 OP
AND SAFETY ACKNOWLEDGMENT REMAINS OF THE ABOVE NAMED DECEDENT UNDER PROVISIONS OF HEALTH AND SAFETY CODE SECTION
CODE OF
SECTIONS 7054.6
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 SIGNATURE L REGIST NG PERMIT / �
HEALTH AND SAFETY CODE AND IS THE AUTHORITY FOR THE DISPOSITION
SPECIFIED IN THIS PERMIT Chg 2;00 7-12-76 .1'2I
SIGNATURE OF PERSON IN CHARGE OF CEMETERY OR OTHER DISPOSITION
I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON ,
(ENTER DATE)
COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION. THE PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR COMPLETING THE PERMIT AND FORWARDING THE COM-
PLETED PERMIT WITHIN ID DAYS TO THE LOCAL REGISTRAR OF THE DISTRICT IN WHICH DISPOSITION OCCURRED OR TO THE LOCAL REGISTRAR 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 STATE REGISTRAR OF VITAL STATISTICS (REV. 7-1-73) FORM VS-9