Harris, Agnes APPLICATIDN 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
AGNES K. HARRIS
2.SEX 3.DATE OF BIRTH(MONTH,DAY,YEAR) 4.DATE OF DEATH (MONTH,DAY,YEAR) 5.(FETAL BATH ONLY)DATE OF EVENT(MONTH,DAY,YEAR)
F 08/05/1928 12/10/2015
6A.CITY OF DEATH 68.COUNTY OF DEATH-IF OUTSIDE OF CALIFORNIA,ENTER STATE
ALAMO CONTRA COSTA
7A.NAME OF INFORMANT 78.RELATIONSHIP TO DECEDENT 8A.TYPED NAME AND ADDRESS OF CALIFORNIA- 8B.CALIFORNIA LICENSE
JURY R.WEISSMAN DAUGHTER LICENSED FUNERAL DIRECTOR OR PERSON NUMBER-IF APPLICABLE
ACTING AS SUCH-STREET NUMBER AND NAME.
CITY,STATE,ZIP CODE FD2088
7C.INFORMANT'S FULL MAILING ADDRESS-STREET NUMBER AND NAME,CITY,STATE,ZIP CODE GRAHAM-HITCH CREMATION AND MEMORIAL
448 RED WING DRIVE,ALAMO, CA 94507 CENTER
125 RAILROAD AVENUE, DANVILLE,CA 94526
ACKNOWLEDGEMENT OF APPLICANT-I hereby acknowledge as applicant that I have the 9A.APP NT SIGNATUR 9B.DATE SIGNED
right to control disposition pursuant to Health&Safety Code Section 7100,and that the disposition 12/15/2015
stated herein is one of the dispositions authorized by Health&Safety Code Section 103055.
PERMIT AND AUTHORIZATION OF LOCAL REGISTRAR-ANY CHANGE IN DISPOSI N REQ RES A EW/ERMIT TO SHOW FINAL DISPOSITION
This permit is issued in accordance with provisions of the California Health and Safety Code and is the a the ' 'on in is 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 12/14/2015 0. WILLIAM WALKER M.D. 40.
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
CONTRA COSTA HEALTH DEPARTMENT
10 DOUGLAS DR., STE.220
MARTINEZ, CA 94553 -
11.AUTHORIZED DISPOSITION(S) FOR CORONER'S USE ONLY
TRANSIT
12A NAME AND ADDRESS OF CALIFORNIA CEMETERY 1213.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)
13A.NAME AND ADDRESS OF CALIFORNIA CREMATORY 13B.DATE CREMATED 13C.CREMATION NUMBER-IF APPLICABLE
iz-<g-I $ 9C
CREMATION 13D.SIGNAT RE OF PERSON IN CHARGE OF CREMATION
14A.NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 148. /E RECEIVED
-I$-/5
SCIENTIFIC USE 14C.SIGNATU PERSON IN CHARGE OF FACILITY
A CJ
15A.NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE REMAINS OR 15B. E AND ADDRESS OF PERSON IN CHARGE OF PLACING WITH THE CARRIER
CREMATED REMAINS ARE TO BE SHIPPED Z,
PINE VIEW CREMATORY, 5O QUAKER ROAD,
TRANSIT QUEENSBURG, NY 12804
15C.SIGNATURE OF PERSON IN CHARGE OF PLACING WITH 15D.DATE SHIPPED
THE CARRIER
16A.ADDRESS,NEAREST POINT ON SHORELINE,OR OTHER DESCRIPTION 168.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.01/012008