Schenk, Ronald •
4 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
RONALD EDWARD SCHENK
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 07/05/1945 11/12/2013
6A.CITY OF DEATH 66.COUNTY OF DEATH-IF OUTSIDE OF CALIFORNIA,ENTER STATE
SACRAMENTO SACRAMENTO
7A.NAME OF INFORMANT 7B.RELATIONSHIP TO DECEDENT 8A.TYPED NAME AND ADDRESS OF CALIFORNIA- 8B.CALIFORNIA LICENSE
LICENSED FUNERAL DIRECTOR OR PERSON
JAM ES A. MOORE CONSERVATOR ACTING AS SUCH-STREET NUMBER AND NAME, NUMBER-IF APPLICABLE
CITY,STATE,ZIP CODE FD134
7C.INFORMANT'S FULL MAILING ADDRESS-STREET NUMBER AND NAME,CITY,STATE,ZIP CODE
P. O. BOX 163657, SACRAMENTO, CA 95816 W F GORMLEY SONS
2015 CAPITOL AVE, SACRAMENTO, CA 95811
ACKNOWLEDGEMENT OF APPLICANT-I hereby acknowledge as applicant that I have the 9A.APPLICANT GNATTUU/.RRE, 9B.DATE S IGNED
right to control disposition pursuant to Health&Safety Code Section 7100,and that the disposition .'ry,f 11/15/2013
stated herein is one of the dispositions authorized by Health&Safety Code Section 103055.
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 106.DATE PERMIT ISSUED 10C.SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
$ 11.00 11/15/2013 II. OLIVIA KASIRYE, MD
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
SACRAMENTO PUBLIC HEALTH -
7001 EAST PARKWAY, SUITE 600
SACRAMENTO, CA 95823 --
11.AUTHORIZED DISPOSITION(S) FOR CORONER'S USE ONLY
CREMATION/TRANSIT
12A.NAME AND ADDRESS OF CALIFORNIA CEMETERY 12B.DATE BURIED 12C.INTERMENT NUMBER-IF APPLICABLE
BURIAL OR
SCATTERING IN A
CEMETERY(INCLUDES 12D.SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING
ENTOMBMENT)
13A.NAME AND ADDRESS OF CALIFORNIA CREMATORY 13B,DATE CREMATED 13C.CREMATION NUMBER-IF APPLICABLE
NORTH SACRAMENTO MEMORIAL if-/7-Zola
CREMATION CREMATORY, 725 EL CAMINO AVE, 13D.SIGNATURE 0 ' -SON I P" --., c REMATION
SACRAMENTO, CA 95815 �� ...
14A.NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS i 14B.DATE R ED
SCIENTIFIC USE 14C.SIGNATURE OF PERSON IN CHARGE OF FACILITY
15A.NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE REMAINS OR 156.NAME AND ADDRESS OF PERSON IN CHARGE OF PLACING WITH THE CARRIER
CREMATED REMAINS ARE TO BE SHIPPED
PINE VIEW CEMETERY, 21 QUAKER ROAD,
TRANSIT QUEENSBURY, NEW YORK, 12804
15C.SIGNATURE OF PERSON IN CHARGE OF PLACING WITH 15D.DATE SHIPPED
THE CARRIER
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