The URL can be used to link to this page

Thomas, Jonathan • APPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS USE BLACK INK ONLY-MAKE NO ERASURES,WHITEOUTS,PHOTOCOPIES,OR OTHER ALTERATIONS IA.NAME OF DECEDENT-FIRST 1 B.MIDDLE I C.LAST Jonathan J. Thomas 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 05/06/1943 09/06/2006 6A.CITY OF DEATH 6B.COUNTY OF DEATH-IF OUTSIDE OF CALIFORNIA,ENTER STATE Fountain Valley Orange 7A.NAME OF INFORMANT 7B.RELATIONSHIP TO DECEDENT 8A.TYPED NAME AND ADDRESS OF CALIFORNIA- 8B.CALIFORNIA LICENSE LICENSED FUNERAL DIRECTOR OR PERSON NUMBER-IF APPLICABLE ACTING AS SUCH-STREET NUMBER AND NAME, Roberta Sue Thomas Wife CITY,STATE,ZIP CODE FD1704 7C.INFORMANTS FULL MAILING ADDRESS-STREET NUMBER AND NAME,CITY,STATE,ZIP CODE Cremation Society of Orange Coast 19012 Woodward Lane 12425 Lewis St.#102 Huntington Beach,CA 92646 Garden Grove,CA 92840 ACKNOWLEDGEMENT OF APPLICANT-I hereby acknowledge as applicant that I have the 9A.APPLICANT SIGNATURE 98.DATE SIGNED right to control disposition pursuant to Health&Safety Code Section 7100,and that the disposition 9/O/ l 2.2 I b 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 10B.DATE PERMIT ISSUED 10C.SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT $ 12.00 SEP 0 1 2016 ► to.. o *Lt#9 C/ 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 Orange Health Department 1200 N. Main Street#100-A Santa Ana,CA 92701 11.AUTHORIZED DISPOSITION(S)-CHECK APPLICABLE ITEMS FOR CORONER'S USE ONLY ❑A.BURIAL OR SCATTERING IN A CEMETERY ❑D.SCIENTIFIC USE 0 I. DISPOSITION PENDING-LOCATION OF REMAINS- (INCLUDES ENTOMBMENT) 0 E.TEMPORARY ENVAULTMENT NAME AND ADDRESS ❑B.CREMATION l F. DISINTERMENT ❑C.DISPOSITION OF CREMATED REMAINS ❑G.SHIP IN TO CALIFORNIA OTHER THAN IN A CEMETERY gi H.TRANSIT OUTSIDE OF CALIFORNIA 12A.NAME AND ADDRESS OF CALIFORNIA CEMETERY 12B.DATE BURIED 12C.INTERMENT NUMBER-IF APPLICABLE BURIAL OR SCATTERING IN A CEMETERY 12D.SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING (INCLUDES ENTOMBMENT) l► 13A.NAME AND ADDRESS OF CALIFORNIA CREMATORY 138.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 l► 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 TRANSIT Pine View Cemetery 21 Quaker Road 15C.SIGNATURE OF PERSON IN CHARGE OF PLACING WITH 15D.DATE SHIPPED Queensbury, NY 12804 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 LAT UDE AND LONGITUDE ©_ I BURIAL AT SEA OR ?)�� _/ / 6 DISPOSITION Y t��j C��YYY��-�TT OTHER THAN IN A 16D. GNATURE OF PERSON IN CHARGE OF SCATTERING OR BURIAL CEMETERY • r_ 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 9 Rev.01/01/2008