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Home My WebLink Aboutvs9-eform-permitUPON 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 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 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) 6A. CITY OF DEATH 6B. COUNTY OF DEATH—IF OUTSIDE OF CALIFORNIA, ENTER STATE 7A. NAME OF INFORMANT 7B. RELATIONSHIP TO DECEDENT 8A. TYPED NAME AND ADDRESS OF CALIFORNIA- LICENSED FUNERAL DIRECTOR OR PERSON ACTING AS SUCH—STREET NUMBER AND NAME, CITY, STATE, ZIP CODE 8B. CALIFORNIA LICENSE NUMBER—IF APPLICABLE 7C. INFORMANT’S FULL MAILING ADDRESS—STREET NUMBER AND NAME, CITY, STATE, ZIP CODE ACKNOWLEDGEMENT OF APPLICANT–I hereby acknowledge as applicant that I have the right to control disposition pursuant to Health & Safety Code Section 7100, and that the disposition stated herein is one of the dispositions authorized by Health & Safety Code Section 103055. 9A. APPLICANT SIGNATURE ► 9B. DATE SIGNED 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 ► 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 11. AUTHORIZED DISPOSITION(S)—CHECK APPLICABLE ITEMS FOR CORONER’S USE ONLY A. BURIAL OR SCATTERING IN A CEMETERY (INCLUDES ENTOMBMENT) B. CREMATION C. DISPOSITION OF CREMATED REMAINS OTHER THAN IN A CEMETERY D. SCIENTIFIC USE E. TEMPORARY ENVAULTMENT F. DISINTERMENT G. SHIP IN TO CALIFORNIA H. TRANSIT OUTSIDE OF CALIFORNIA I. DISPOSITION PENDING—LOCATION OF REMAINS— NAME AND ADDRESS 12B. DATE BURIED 12C. INTERMENT NUMBER—IF APPLICABLE BURIAL OR SCATTERING IN A CEMETERY (INCLUDES ENTOMBMENT) 12A. NAME AND ADDRESS OF CALIFORNIA CEMETERY 12D. SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING ► 13B. DATE CREMATED 13C. CREMATION NUMBER—IF APPLICABLE CREMATION 13A. NAME AND ADDRESS OF CALIFORNIA CREMATORY 13D. SIGNATURE OF PERSON IN CHARGE OF CREMATION ► 14B. DATE RECEIVED SCIENTIFIC USE 14A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS 14C. SIGNATURE OF PERSON IN CHARGE OF FACILITY ► 15B. NAME AND ADDRESS OF PERSON IN CHARGE OF PLACING WITH THE CARRIER TRANSIT 15A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED 15C. SIGNATURE OF PERSON IN CHARGE OF PLACING WITH THE CARRIER ► 15D. DATE SHIPPED 16B. DATE OF DISPOSITION 16C. LICENSE NUMBER OF CREMATED REMAINS DISPOSER—IF APPLICABLE SCATTERING/ BURIAL AT SEA OR DISPOSITION OTHER THAN IN A CEMETERY 16A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND CALIFORNIA DISTRICT OF DISPOSITION; IF BURIAL AT SEA, ONLY ENTER LATITUDE AND LONGITUDE 16D. SIGNATURE OF PERSON IN CHARGE OF SCATTERING OR BURIAL ► INSTRUCTIONS FOR COPY DISTRIBUTION COPY 1 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 2 RETAINED BY THE 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 RETURNED TO THE COUNTY OF DEATH WHEN THE REMAINS ARE DISPOSED OF IN ANOTHER DISTRICT. IF NOT APPLICABLE, COPY 3 MAY BE DISCARDED. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE. COPY 4 RETAINED BY THE REGISTRAR ISSUING THE PERMIT. THE LOCAL REGISTRAR MAY DESTROY ANY ORIGINAL OR DUPLICATE PERMIT AFTER ONE YEAR FROM ISSUE DATE. SPECIAL INSTRUCTIONS REGARDING CREMATION THE FOLLOWING STATUTORY PROVISIONS ARE APPLICABLE TO THE DISPOSITION OF CREMATED HUMAN REMAINS OTHER THAN IN A CEMETERY AND BURIAL AT SEA AFTER CREMATION AS PROVIDED IN HEALTH AND SAFETY CODE SECTIONS 7054.6, 7054.7, 7116, 7117, AND 103060. NO PERSON SHALL DISPOSE OF OR OFFER TO DISPOSE OF ANY CREMATED HUMAN REMAINS UNLESS REGISTERED AS A CREMATED REMAINS DISPOSER BY THE STATE CEMETERY BUREAU. THIS ARTICLE SHALL NOT APPLY TO ANY PERSON, PARTNERSHIP, OR CORPORATION HOLDING A CERTIFICATE OF AUTHORITY AS A CEMETERY, CREMATORY LICENSE, CEMETERY BROKER’S LICENSE, CEMETERY SALESPERSON’S LICENSE, OR FUNERAL DIRECTOR’S LICENSE, NOR SHALL THIS ARTICLE APPLY TO ANY PERSON HAVING THE RIGHT TO CONTROL THE DISPOSITION OF THE CREMATED REMAINS OF ANY PERSON OR THAT PERSON’S DESIGNEE IF THE PERSON DOES NOT DISPOSE OF OR OFFER TO DISPOSE OF MORE THAN 10 CREMATED HUMAN REMAINS WITHIN ANY CALENDAR YEAR. (BUSINESS AND PROFESSIONS CODE SECTION 9740.) CREMATED REMAINS MAY BE SCATTERED IN AREAS WHERE NO LOCAL PROHIBITION EXISTS, PROVIDED THAT THE CREMATED REMAINS ARE NOT DISTINGUISHABLE TO THE PUBLIC, ARE NOT IN A CONTAINER, AND THAT THE PERSON WHO HAS CONTROL OVER DISPOSITION OF THE CREMATED REMAINS HAS OBTAINED WRITTEN PERMISSION OF THE PROPERTY OWNER OR GOVERNING AGENCY TO SCATTER ON THE PROPERTY. A STATE OR LOCAL AGENCY MAY ADOPT AN ORDINANCE, REGULATION, OR POLICY, AS APPROPRIATE, AUTHORIZING, CONSISTENT WITH THIS SECTION, OR SPECIFICALLY PROHIBITING, THE SCATTERING OF CREMATED HUMAN REMAINS ON LANDS UNDER THE AGENCY’S JURISDICTION. THE SCATTERING OF THE CREMATED REMAINS OF MORE THAN ONE PERSON IN ONE LOCATION PURSUANT TO THIS SECTION SHALL NOT CREATE A CEMETERY PURSUANT TO SECTION 7003 OR ANY OTHER PROVISON OF LAW. (HEALTH AND SAFETY CODE SECTION 7116.)