Dufour, Thomas APPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS
USE BLACK INK ONLY-MAKE NO ERASURES,WHITEOUTS,PHOTOCOPIES,OR OTHER ALTERATIONS
1A.NAME OF DECEDENT-FIRST ,1B.MIDDLE 1C.LAST
THOMAS ; A. DUFOUR
2.SEX 3.DATE OF BIRTH (MONTH,DAY,YEAR) 4.DATE OF DEATH (MONTH,DAY,YEAR) 5.(FETAL DEATH ONLY)DATE OF EVENT(MONTH,DAY,YEAR)
M 08/15/1961 09/03/2011 FND
6A.CITY OF DEATH 68.COUNTY OF DEATH-IF OUTSIDE OF CALIFORNIA,ENTER STATE
LOS ANGELES LOS ANGELES
7A.NAME OF INFORMANT 7B.RELATIONSHIP TO DECEDENT 8A.TYPED NAME AND ADDRESS OF CALIFORNIA- 8B.CALIFORNIA LICENSE
JOSEPH A. DEFOUR FATHER LICENSED FUNERAL DIRECTOR OR PERSON NUMBER-IF APPLICABLE
ACTING AS SUCH-STREET NUMBER AND NAME,
CITY,STATE,ZIP CODE FD1557
7C.INFORMANTS FULL MAILING ADDRESS-STREET NUMBER AND NAME,CITY,STATE,ZIP CODE MIDGLEY-GARDENSIDE MORTUARY
22 GAGE AVENUE 13450 PARAMOUNT BLVD#B
GLENS FALLS, NY 12801 SOUTH GATE, CA 90280-8251
ACKNOWLEDGEMENT OF APPLICANT-I hereby acknowledge as applicant that I have the 9A.APPLICANT SIGNATURE 9B.DATE SIGNED
right to control disposition pursuant to Health&Safety Code Section 7100,and that the disposition stated herein is one of the dispositions authorized by Health&Safety Code Section 103055. ► tel J-Cy/ - j/C6/
PERMIT AND AUTHORIZATION OF LOCAL REGISTRAR-ANY CHANGE IN DISPOSITION REQUIRES A NEW PERMIT TO SHOW FINAL DISPOSITION
This permit is issued in accordance with provisions of the California Health and Safety Code and is the authority for the disposition specified in this permit.NOTE:This permit gives no right of disposal outside
of California.
10A.AMOUNT OF FEE PAID 10B.DATE PERMIT ISSUED 10C.SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
$ 11.00 09/08/2011 ► JONATHAN FIELDING, MD k ,
10D.ADDRESS OF REGISTRAR OF DISTRICT OF DEATH-IF DEATH OCCURRED IN CALIFORNIA 10E.ADDRESS OF REGISTRAR OF DISTRICT OF DISPOSITION-IF DIFFERENT FROM 10D
LOS ANGELES CO DEPT OF PUBLIC HEALTH
313 NORTH FIGUEROA STREET, RM L-1
LOS ANGELES, CA 90012 --
11.AUTHORIZED DISPOSITION(S) FOR CORONER'S USE ONLY
TR
•
12A.NAME AND ADDRESS OF CALI JIA CEMETERY 12B.DATE BURIED 12C,INTERMENT NUMBER-IF APPLICABLE
BURIAL OR �( AJ ,p /� /
SCATTERING IN A - /. ///J�J,;rer f1> �1 Cp14C e.y. v'i/3///
CEMETERY �" i/ 12D.SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING
(INCLUDES L G LNG a/ ✓'r)
ENTOMBMENT) j
13A.NAME AND ADDRESS OF CALIFORNIA CREMATORY 13B.DATE CREMATED :13C.CREMATION NUMBER-IF APPLICABLE
CREMATION 13D.SIGNATURE OF PERSON IN CHARGE OF CREMATION
►
14A.NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 14B.DATE RECEIVED
SCIENTIFIC USE 14C.SIGNATURE OF PERSON IN CHARGE OF FACILITY
►
15A.NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE REMAINS OR 15B.NAME AND ADDRESS OF PERSON IN CHARGE OF PLACING WITH THE CARRIER
CREMATED REMAINS ARE TO BE SHIPPED
REGAN AND DENNY FUNERAL HOME
TRANSIT 53 QUAKER ROAD
QUEENSBURY, NY 12804 THE CARRITURE OF PERSON IN CHARGE OF PLACING WITH 15D.DATE SHIPPED
ER
16A.ADDRESS,NEAREST POINT ON SHORELINE,OR OTHER DESCRIPTION 16B.DATE OF DISPOSITION 16C.LICENSE NUMBER OF CREMATED
SUFFICIENT TO IDENTIFY FINAL PLACE AND CALIFORNIA DISTRICT OF DISPOSITION; REMAINS DISPOSER-IF APPLICABLE
SCATTERING/ IF BURIAL AT SEA,ONLY ENTER LATITUDE AND LONGITUDE
BURIAL AT SEA OR
DISPOSITION -
OTHER THAN IN A 16D,SIGNATURE OF PERSON IN CHARGE OF SCATTERING OR BURIAL
CEMETERY
►
UPON AUTHORIZATION OF PERMIT,DISTRIBUTE COPIES AS FOLLOWS:
COPY 1-ACCOMPANIES REMAINS TO THE STATED PLACE OF DISPOSITION. PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR COMPLETING AND FORWARDING THE PERMIT
WITHIN 10 DAYS OF DISPOSITION TO THE REGISTRAR OF THE DISTRICT IN WHICH DISPOSITION OCCURRED OR THE DISTRICT NEAREST THE POINT WHERE THE CREMATED REMAINS
WERE SCATTERED AT SEA.'
COPY 2-RETAINED BY PERSON IN CHARGE OF THE CEMETERY,CREMATORY,FACILITY FOR SCIENTIFIC USE,OR BY THE PERSON IN CHARGE OF DISPOSING OF THE CREMATED REMAINS.
COPY 3-RETURN TO COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT.IF NOT APPLICABLE,COPY 3 MAY BE DISCARDED.'
COPY 4-RETAINED BY REGISTRAR ISSUING THE PERMIT.*
THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE.
STATE OF CALIFORNIA,DEPARTMENT OF PUBLIC HEALTH,OFFICE OF VITAL RECORDS VS 9e Rev.01/01/2008