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West, Christine APPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS USE BLACK INK ONLY-MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS 1A. NAME OF DECEDENT-FIRST (GIVEN) 1B. MIDDLE 1C. LAST (FAMILY) 2. DATE OF BIRTH 3. DATE OF DEATH 4. SEX CHRISTINE - l �rr M60N29D5y YEAR M102_9DAY 9 YEAR FE 5A. CITY OF DEATH 15B. COUNTY OF DEATH-OUTSIDE CALIFORNIA. TER STATE 6. NAME, RELATIONSHIP, MAILING ADDRESS AND ZIP CODE San Francisco San Francisco June RWest, mother 7A. TYPED NAME AND ADDRESS OF APPLICANT-FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 178. CAL OR IA L ENSE NUMBER 140 Meadowbrook Road I APP ICABL- Regan & Denny Funeral Home Queensbury, NY ' - Queensbury, NY 12804 ACKNOWLEDGMENT I hereby acknowledge as applicant that the proposed disposition stated herein is one 8A. GNATUR OF A P IC T-Funeral Direc Acting as Such 18B. DATE SIGNED OF of the dispositions authorized by Section 10376 of the Health and Safety Code,and APPLICANT was authorized pursuant to Section 7100 of the Health and Safety Code. ► ' fi.� ©e` l PERMIT THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVI- 9A LINT OFF E PA 9B. DATE PERMIT ISSUED 9C.SIGNATURE OF LOCAL REGISTRAR ISSUING PERMIT SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODEy��JJJ I I AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED "/ AUTHORIZATION OF IN THIS PERMIT. LOCAL REGISTRAR NOTE:TINS PONT GIVES ND RIGHT OF DISPOSAL WTSDE OF CALOORMIL ► ANY CHANGE IN DISPOSI 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- 19E. ADDRESS OF REGISTRAR OF DISTRI OF DIS SITION- TION REQUIRES A NEW IF DEATH OCCURRED IN CALIFORNIA I IF DISPOSITION IS TO OCCUR IN ANOTHER DISTR T IN CALIFORN PERMIT TO SHOW FINAL DISPOSITION. 101 Grove St. S.F. CA 94102 I I 10. TYPE OF DISPOSITION(S) AUTHORIZED CHECK ALL APPLICABLE ITEMS G. SHIP IN TO CALIFORNIA A. BURIAL (INCLUDES ENTOMBMENT) D. SCIENTIFIC USE H. TRANSIT TO OUTSIDE OF CALIFORNIA . CREMATION E. TEMPORARY ENVAULTMENT FOR CORONER'S USE ONLY C. DISPOSITION OF CREMATED REMAINS OTHER F. DISINTERMENT THAN IN A CEMETERY I. DISPOSITION PENDING 11A. NAME AND ADDRESS OF CEMETERY 111B. DATE INTERREDI 11C. SIGNATURE OF PERSON IN CHARGE OF INTERMENT INTERMENT - I I 1 ► 12A. NAME AND DRESS OF CREMATORY 12B.DATE CREMATED 12C. SIG TURE OF PERSON IN CHAR OF CREMATION �'n/,� T�'�i'll/4 w '1 /aZ `j3 CREMATION � N/ C m U I I 0 13A. NAME AND ADDRESS OF FACILITY RECEIVING REMAINS 13B. DATE RECEIVED 13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY a SCIENTIFIC I I USE u+ 14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE 148. DATE SHIPPED 14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED OF TRANSIT TRANSIT Regan & Denny Funeral Home 26 Ouaker Rd. Oueensbury, NY I too- SCATTERING AT SEA 15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION 15B. DATE OF 15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER OR SUFFICIENT TO IDENTIFY FINAL PLACE AND DISTRICT OF DISPOSITION DISPOSITION CHARGE OF DISPOSITION OF CREMATED RE- DISPOSITION OTHER - I l MAINS DISPOSER HAN IN A CEMETERY -IF APPLICABLE I I ► COPY 1 OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION. THE 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. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE. COPY 9 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS (REV.5/89)