Whiting, Danon APPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS - (-
USE BLACK INK ONLY-MAKE NO ERASURES,WHITEOUTS,PH TOCOPIES,OR OTHER ALTERATIONS
1A NAME or DECEDENT-FIRST :1B.MIDDLE 1C.LAST
DANON K WHITING
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 01/28/1980 01/28/2013
6A.CITY OF DEATH 6B.COUNTY OF DEATH-IF OUTSIDE OF CALIFORNIA,ENTER STATE
ONTARIO SAN BERNARDINO
7A.NAME OF INFORMANT ;7B.RELATIONSHIP TO DECEDENT BA TYPED NAME AND ADDRESS OF CALIFORNIA- 8B.CALIFORNIA LICENSE
MARIAH WHITING WIFE LICENSED FUNERAL DIRECTOR OR PERSON
ACTING AS SUCH-STREET UMBER AND NAME, NUMBER-IF APPLICABLE
CITY,STATE,ZIP CODE FD-1276
7C.INFORMANTS FULL MAILING ADDRESS-STREET NUMBER AND NAME,CITY,STATE,ZIP CODE
1601 BARTON ROAD#1307, REDLANDS, CA 92373 AKES FAMILY FUNERAL HOME
9695 MAGNOLIA AVENUE, RIVERSIDE, CA 92503
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 Q_ M -_ �L 01/29/2013
stated herein is one of the dispositions authorized by Health&Safety Code Section 103055. P`8"✓t� C.X�L 1W c'y�
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 i10C.SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT
$ 11.00 01/30/2013 MAXWELL 111 OHIKHUARE, 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
SAN BERNARDINO HEALTH DEPARTMENT
340 NORTH MOUNTAIN VIEW AVENUE
SAN BERNARDINO, CA 92415-0010 --
11.AUTHORIZED DISPOSITION(S) FOR CORONER'S USE ONLY
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
-E�inir� �t rrN Ate/ �-c/73
CREMATION 13D.SIGNATUR OF P RSON IN ARGE OF CREMATION
190c-r1s444 At /)i d
14A.NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS .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 AKES FAMILY FUNERAL HOME- E.RANDY AKES,JR.
TRANSIT JILLSON FUNERAL HOME, INC. 46 WILLIAM 9695 MAGNOLIA AVENUE,RIVERSIDE,CA.92503
STREET WHlTEHALL, NEW YORK 12887-0268 15C.SIGNATURE OF PERSON IN CHARGE OF PLACING WITH 15D.DATE SHIPPED
THE CARRIER ,�.�"�' ✓
C/J f0`��`/JI 01/31/2013
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