Patch, Curtis #45915
Bonham Bros,/Joseph-Saum
PERMIT FOR DISPOSITION OF HUMAN REMAINS
NAME OF DECEDENT SEX DATE OF BIRTH DATE OF DEATIj)UA
CURTIS LEE PATCH Male January 8, 1948 Dec. 19, 1979
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
San Diego San Diego Robert B. Patch (Father)
NAME OF FUNERAL DIRECTOR (OR PERSON ACTING As SUCH) CALIFORNIA LICENSE NUMBER 4 Carlton Drive
Bonham Bros./Johnson-Saum ; 567 Glens Falls, NY 12846
TYPE OF PERMIT. CHECK ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
❑ 5. DISINTERMENT AND BURIAL (INCLUDES ❑8. DISINTERMENT AND REINTERMENT OF CREMATED
❑ 1. BURIAL (INCLUDES ENTOMBMENT) ENTOMBMENT) REMAINS (INCLUDES INURNMENT)
Xi 2. CREMATION AND BURIAL (INCLUDES INURNMENT) ❑ 6. DISINTERMEPIL_CREMATION. AND BURIAL
❑3. CREMATION AND DISPOSITION OTHER THAN IN A (INCLUDES INURNMENT)
CEMETERY ❑7. DISINTERMENT, CREMATION, AND DISPOSITION ❑9. DISINTERMENT OF CREMATED REMAINS AND
❑4. SCIENTIFIC USE OTHER THAN IN A CEMETERY DISPOSITION OTHER THAN IN A CEMETERY
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 INVALIDATE EACH LINE NOT REQUIRED FOR THE SPECIFIED DISPOSITION.
NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED ;COUNTY
BURIAL N/A
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREMATED DATE CREMATED SIGNATURE OF PERSON IN CHARGE OF CREMATORY
CREMATION Cypress View Crematory-San Diego, Calif.
INTERMENT NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED ;COUNTY
AFTER
CREMATION Pine View Cemetery - Glens Falls, New York ' Warren
BURIAL AT SEA ADDRESS. NEAREST POINT ON SHORELINE. OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF DISPOSITION
OR
DISPOSITION OTHER
THAN IN A CEMETERY N/A
OF CREMATED REMAINS
This is to certify that I am the person having the right to control the disposition of the SIGNATURE OF APPLICANT
ACKNOWLEDGMENT remains of the above named decedent under provisions of the Health and Safety Code, '
OF
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.
SCIENTIFIC NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
USE N/A
LOCAL THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF AMOUNT OF FEE PAID DATE PERMIT ISSUED SIG E OF R TRAR ISSUING PERMIT
REGISTRAR THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE /�/� ^ �) Al)
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT $ 2.00 nr 1. 2 1q7 �"'.;�1?. y!r,^ /� �/•
CERTIFICATION /e SIGNATURE OF PERSON IN CHARGE OF DISPOSITION
OF PERSON IN CHARGE I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON_ OP.
DISPOSITION (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 10 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 SERVICES—OFFICE OF THE STATE REGISTRAR OF VITAL STATISTICS (REV. 5-78) FORM VS-9