RIVERSIDE COUNTY

STAN SNIFF, SHERIFF CORONER-PUBLIC ADMINISTRATOR

Sheriff CORONER-PUBLIC ADMINISTRATOR

Rubidoux Mortuary Kimberly Family Chapel

6091 Mission Boulevard

Riverside, California 92509

(951) 683 2215

FAX (951) 683 3509

INDIGENT CREMATION/BURIAL PROGRAM

800 S. REDLANDS AVE, PERRIS, CA 92570

The Riverside County Indigent Cremation/Burial Program is designed to help families who, at this difficult time are financially unable

to pay for a funeral. The county has chosen direct cremation without services simply to streamline the costs. The amount loaned is

not to be considered as a supplement to funds already available to the family or decedent for funeral arrangements.

Upon approval applicants are limited to a total not to exceed:

Area One - $375.00

Area Two - $500.00

Area Three - $750.00

Area One: West of Cabazon to the Riverside County Western County Line and South to the San Diego County Line.

Area Two: East of Whitewater area to Riverside County Eastern County Line Including Desert Center and South to San

Diego County Line

Area Three: Desert Center east to county line including the Blythe Area

Rubidoux Mortuary is the contract mortuary for the County of Riverside. Please return the completed applications directly to them.

All applications must include proof of the applicant's income and most recent bank statement, if any. Incomplete applications or

applications without the attachments may not be considered.

If the applicant has received donations. if there is an insurance policy or any other benefits that would pay for the decedent's

disposition. DO NOT APPLY. If the decedent is an infant, both parents must sign the cover sheet. sign the application and provide

proof of income and residency of the application may be denied.

THIS IS A LOAN. YOU ARE EXPECTED TO REPAY THE COUNTY OF RIVERSIDE PUBLIC ADMINISTRATOR UNTIL THE LOAN IS PAID IN

FULL. IMMEDIATELY UPON APPROVAL, YOU WILL RECEIVE A LETTER ADVISING YOU OF THE AMOUNT OWED AND WHEN AND

WHERE YOU SHOULD SEND YOUR PAYMENT. IF AFTER SIX MONTHS, NO PAYMENT IS RECEIVED BY THE COUNTY, YOUR ACCOUNT

MAY BE TURNED OVER TO A COLLECTION AGENCY.

Please mark the appropriate box for re-payment, which is most suitable for your needs:

$50.00 per month until paid in full.

$25.00 per month until paid in full.

$10.00 per month until paid in full.

APPLICANT'S NAME (PRINT) APPLICANT'S SIGNATURE

CO-APPLICANT'S NAME (PRINT) CO-APPLICANT'S SIGNATURE

DATE DATE

APPLICATION FOR INDIGENT

CREMATION/BURIAL

1. DECEDENT'S NAME _ ___ ________ ____ SOC.SEC. ________ _ _

DECEDENT'S ADDRESS _____________ _______________ _

BIRTHDATE ______ PLACE ________________ D.O.D .. _____ _

CAUSE OF DEATH. ______________ LOCATION OF REMAINS _______ _

MARITAL STATUS: MARRIED ( ) DIVORCED ( ) WIDOWED ( ) NEVER MARRIED ( )

DECEDENT WEIGHT _____ _

VETERAN: YES ( ) NO ( ) SERVICE/BRANCH _________ _

2. DECEDENT'S EMPLOYER. ___ ____________ MONTHLY INCOME ______ _

OTHER SOURCE OF INCOME: _____________ MONTHLY

INCOME _____ _ _

(SOCIAL SECURITY, VA PENSION, EMPLOYMENT PENSIONS, DIVIDENDS, ANNUITY, ETC.)

NUMBER OF DEPENDENTS: ______ _

3. SAVINGS: YES ( ) NO ( ) BALANCE. _____ CHECKING: YES ( ) NO ( ) BALANCE ____ _ _

NAME OF BANK BRANCH _____________ LOCATION __________ _

DECEDENT'S NAME __________ _

4. REAL PROPERTY:

OWN: YES { ) NO { ) MONTHLY PAYMENT _______ RENT: YES ( ) NO ( )

MONTHLY PAYMENT _____ LOCATION: __________________ _

{STREET, CITY ST. ZIP)

S. VEHICLES: YES ( ) NO ( LOCATION ___________________ _

REGISTRATION NO. _________ MAKE ________ MODEL _____ _

6. OTHER ASSETS: (CASH, CHECKS, ETC.)

7. LIFE INSURANCE YES ( ) NO ( ) IF YES, NAME OF COMPANY _____________ _

FACE VALUE _ _ _ _ _______ POLICY# _____ __________ _

1.

2.

DECEDENT'S NAME _________ _

NEXT-OF-KIN

PROOF OF INCOME MUST BE ATTACHED

APPLICANT' S NAME ___________ RELATIONSHIP TO DECEDENT _______ _

BIRTH DATE ______ SOC. SEC. # __________ TELEPHONE NO. ____ _

ADDRESS

( STREET) (CITY) (ST} (ZIP CODE}

CO-APPLICANT' S NAME _______ _ _ __ RELATIONSHIP TO DECEDENT ______ _

BIRTH DATE _______ soc SEC. # _________ TELEPHONE NO. _____ _

ADDRESS

( STREET) (CITY) (ST} (ZIP CODE}

APPLICANT'S EMPLOYER _____________ MONTHLY INCOME _______ _

OTHER SOURCE OF INCOME OR MEANS OF SUPPORT: MONTHLY INCOME ___________ _

( SOCIAL SECURITY, VA PENSION, EMPLOYMENT PENSIONS, DIVIDENDS, ANNUITY, ETC.}

INCOME VERIFICATION __________________________ _

MOST RECENT PAYSTUB; PROOF OF AFDC; BANK STATEMENT

NUMBER OF DEPENDENTS: ________ _

CO- APPLICANT'S EMPLOYER _____________ MONTHLY INCOME ______ _

OTHER SOURCE OF INCOME OR MEANS OF SUPPORT: MONTHLY INCOME. ___________ _

( SOCIAL SECURITY, VA PENSION, EMPLOYMENT PENSIONS, DIVIDENDS, ANNUITY, ETc.)

INCOME VERIFICATION __________________________ _

MOST RECENT PAYSTUB; PROOF OF AFDC; BANK STATEMENT

NUMBER OF DEPENDENTS: ________ _

3. APPLICANT'S SAVINGS: YES ( ) NO ( ) BALANCE _____ CHECKING: YES ( ) NO ( )

BALANCE _____ _

NAME OF BANK BRANCH ____________ LOCATION __________ _

DECEDENT'S NAME _________ _

SAVINGS ACCOUNT NO. __________ CHECKING ACCT NO. _________ _

4. APPLICANT'S REAL PROPERTY:

OWN:YES( ) NO( ) MONTHLYPAYMENT ____ RENT: YES( ) NO( )MONTHLYPYMT ___ _

LOCATION: __________________ _

{STREET, CITY ST. ZIP)

MORTGAGE COMPANY _____________ BALANCED OWED ________ _

APPROXIMATE VALUE ____________ _

CO- APPLICANT'S REAL PROPERTY:

OWN:YES{ ) NO( ) MONTHLYPAYMENT ____ RENT: YES( ) NO( )MONTHLYPYMT ___ _

LOCATION: __________________ _

(STREET, CITY ST. ZIP)

MORTGAGE COMPANY _____________ BALANCED OWED ________ _

APPROXIMATE VALUE ____________ _

5. APPLICANT'S VEHICLES ___________________________ _

MAKE/MODEL YEAR LICENSE NO.

CO-APPLICANT'S VEHICLES _______________________________ _

MAKE/MODEL YEAR LICENSE NO.

6. ANY OTHER ASSETS: YES( ) NO ( )

IF YES, EXPLAIN:

7. ANY ADDITIONAL NEXT OF KIN : YES ( ) NO ( ) IF YES, GIVE NAME AND RELATIONSHIP:

NAME RELATIONSHIP

NAME RELATIONSHIP

NAME RELATIONSHIP

NAME RELATIONSHIP

DECEDENT'S NAME ___________ _

MORTUARY RUBIDOUX MORTUARY

NAME OF FUNERAL DIRECTOR/COUNSELOR JENNIFER RUBENSTEIN TAUNYA KIMBERLY

DOES APPLICANT AGREE TO CREMATION: ) YES ( ) NO

IF NO PLEASE EXPLAIN: ________________________ _

TOTAL COST OF FUNERAL $ 375.00 $500.00 $750.00 $ ____ _

DOES NOT INCLUDE COST OF SCATTERING OR SHIPPING CREMAINS

VA CEMETERY INCLUDED ( ) YES ( ) NO

SHOULD THE DECEDENT EXCEED A WEIGHT OF 300 LBS. AN ADDITIONAL CHARGE OF $5.00 PER POUND

WILL BE ADDED. THIS ADDITIONAL FEE IS THE RESPONSIBILITY OF THE NEXT OF KIN SIGNING THIS FORM.

I HAVE BEEN INFORMED OF MY REPORTING RESPONSIBILITIES AND OF MY RIGHT TO APPEAL TO THE

COUNTY OF RIVERSIDE CONCERNING THE DISPOSITION OF THIS APPLICATION. I DECLARE UNDER PENALTY OF

PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE TRUE AND CORRECT. I/WE AGREE TO

REPAY ANY AND ALL AID ADVANCED TO ME BY THE RIVERSIDE COUNTY BOARD OF SUPERVISORS UNDER

DIVISION 9, PART 5, OF THE WELFARE AND INSTITUTIONS CODE OF THE STATE OF CALIFORNIA.

DATE APPLICANT'S SIGNATURE

DATE CO-APPLICANT'S SIGNATURE

DATE APPLICANT'S REPRESENTATIVE

ORDER FOR RELEASE

TO: -----------------------------

DECEDENT: -------------------------The above facility is ordered to release the

above named decedent to:

Rubidoux Mortuary Kimberly Family Chapel

The undersigned represents that he/she has

the legal right to control the disposition of the

remains of the above named decedent.

Signature: ________________________ _

Relationship: ______________________ _

Address: ________________________ _

City, State, Zip:. _____________________ _

Phone ( ) ____________________ _

* SHERIFF-CORONER

COtl\,Y OF RI\IRSIDE

CORO).""E.R BURE..-\l.T- 'WIST 800 S. REDLANDS AVENUE PERRIS, CA 9~570 PHONE: 951-443-2300 INVESTIGATIONS FAX: 951--443-2303 MORGUE FAX: 951-443-2322

TO: SHERIFF-CORONER, County ofRivers-ide

ST . .\..~Y SNIFF SHERIFF-COROl"ff:R

CORO::'.\""ER Bl."RL\.U - E.-\.ST 47-225 OASIS STREET INDIO, CA 92201 PHONE: 760-863-8311 FAX: 760...863-7031 MORGUE FAX: 760-863-7530

Re: _______________ _, Deceased-Coroner File# 20_ _ ___ _

REQUEST FOR RELEASE OF RI.1'l~S J c:ernfy th;,,t, pur.:u.mt to Section ·noo, He:,JtL '1.Dd ~11fe~· Code, !.t:.1te-of Clll if'orni.-t, that it is my ~gal right to control the di.,""?O~ition of ilie remain:. of the above eamed deoedem:. I hereby request lhat you release the remains in your custody to :

Name offuuera] Directorl'Mortu;uy 1',,failing Address, City, State, Zip Telephone Number

The per:on signiDg rim 1·equest i:; liable fur ail dam.are. cau:;ed by any untruthful statement:-. contained :in this document (He:1lth :111d! S:11fety Code Section 7110) . Irj:; aiso a. c:rimmal off'en5e ro forge or knowingly file a fa.be statement with a gm·emment agency (Pen:tl Code Section~ 11:S :ind -t70).

SIGNED _________________ RELATIONSHIP __________ _

ADDRESS __________________ CITY / STATE ___________ _

TELEPHONE Nillv!IBER ____________ DATE SIGNED _______ ___ _

PI.RSONAL PROPERTY .IDYISE1\IE1'"T TLe Sheriff-Coro,ner m:iy &e io pom!1,io11 of penooal propel"ty belonging: to th:1t of the d~edent, Pe..-~on:il propei:tyin tbe pos.eHioo of the $heriff-Corone1· mil be-relea,ed to the fUJ1er:11l Director/hlortu:u;· Agent :it the time that the remain~ ::u-e rele:1s.ed unles.~ specifie belo"·· Regardless, the Sheriff-Coronel' will only maint:lin proper*}· for ninetr d:1·p; from date of de:ith. Propern,· shall be disposed of

:11fter the ninety-d:rr period.

D I elect to pick up the person.11 property from the Sheriff-Coroner within the ninety-day period. I understand that property not picked up within the time period will be disposed of. Call to make an appointment for release.

Signed: _ _ ______________________ _ _ ________ _ _

~R.U. DIRECTOR OR ..\.GE1'--r I CERTIFY Tili\. TI HA VE EXM-fiNED • .\fill INITIALED TOE TAG # \v1IlCH BEARS 1BE NA.\1E OF TIIE ABOVE. NAMED DECEASED AL~ Ri\. VE RECEIVED THE REI\·1AIN,:--::-:=s=-_---

I HAVE ALSO RECETVED THE FOLLO\\'ING ITEMS:

__ _;PERSONAL PROPER.TY r<-:-nAI.

CLO~G ---INIIIAL

REPRESENTATIVE _________ _ SIGNATIJRE _________ _ PRINT NAME

RELE.l\SED BY: DATElfllvfE _________ _

RC~C Fol1D C-Rl006 Re,,.i:;e,d 10/2015

Disclosure of Preneed Funeral Agreement

The funeral establishment, Rubidoux Mortuary, (funeral establishment name)

license number FD 913, DOES __ , DOES NOT _X __ (check one) have a preneed arrangement, as

defined below, made by or on behalf of ____________________ _ (name of decedent)

If the funeral establishment does have a preneed agreement, complete the following:

In compliance with Business and Professions Code Section 7745, the funeral establishment has presented to the person named below a copy of any preneed agreement which has been signed and paid for in full , or in part by, or on behalf of the deceased and is in the possession of the funeral establishment.

Signature of funeral establishment representative Date

"Preneed arrangement," "preneed agreement" or "preneed" is written instruction regarding goods or services or both goods and services for final disposition of human remains when the goods or services are not provided until the time of death, and may be either unfunded or paid for in advance of need.

Funeral Establishment's Responsibility - Business and Professions Code Section 77 45 requires a funeral establishment to present to the survivor of the decedent or the responsible party a copy of any preneed agreement in its possession which has been signed and paid for in full, or in part by, or on behalf of the deceased. Business and Professions Code Section 7685.6 requires a copy of any preneed arrangements to be disclosed prior to drafting any contract for funeral goods or services. The funeral establishment may present the copy in person, by certified mail, or by facsimile transmission, as agreed upon by the person with the right to control disposition. A funeral establishment that knowingly fails to present a preneed agreement as required is liable for a civil fine equal to three times the cost of the preneed agreement, or one thousand dollars ($1 ,000), whichever is greater.

You may contact the Cemetery and Funeral Bureau for more information on funeral, cemetery or cremation matters or to file a complaint against a licensee:

Cemetery and Funeral Bureau 1625 North Market Blvd., Suite S-208 Sacramento, CA 95834 916-574-7870

_x _________________ _ Signature of the survivor or responsible party

Print name of the survivor or responsible party

Signature of funeral establishment representative

Print name of funeral establishment representative

The funeral establishment must:

Date

Date

Title

• G ive a copy of the completed statement to the survivor or responsible party. • Retain the o riginal or a copy of the completed d isclosure statement on file for not less than one (1) year after the preneed account

has been audited by t he Bureau o r seven (7) years from the date the d isclosure statement was made, whichever comes fi rst .

AUTHORIZATION FOR DISPOSITION WITH O R WITHOUT

EMBALMING

TO: RUBIDOUX MORTUARY

RE: ______ _ _____ (DECEDENT)

I, DO _ __ DO NOT ___ X __ (check one) request embalming, which I understand is the addition to,

or the placement of, body fluids be chemica l preservatives of the application of chemical preservatives

for temporary preservation of the body. I understand that embalming is not required by law.

I understand that for the storage or embalming purposes the decedent may be transported to

the following licensed funera l establishment. ______________ _______ n/ a ___________________ _ _ _

then returned for funera l services. I understand that I may be charged an additional fee for transport.

The undersigned hereby represents that he/she has the legal right to control disposition of the remains of the

decedent.

Signed: __ X _________ ______________ __ Relationship: __

Executed this ___ day of ___ ____ , 20 __ , at Riverside, CA

To be completed by funeral establishment if Authorization to Embalm and Notification to transport

Is obtained orally (by telephone):

The above statement of authorization and notification was read to --- --____________________ , Relationship _ _ _____ , who did ____ did not __ _

(check one)

authorize embalming at the above named funeral establishment. C ity _ _______ ____ _

State ________ , phone 95 1-683-2215. Date and time authorization granted:

Signature of funeral establishment representative accepting authorization.

I declare under penalty of perjury that the foregoing is true and correct. Executed this _____ day of ___ ________ ___ _ , at city _ _ _ _______ , State ______ .

(s)

AUTHORIZATION FOR CREMATION AND DISPOSITION

I/We, the undersigned, certify, warrant, and represent that I/We have the full legal right and authority to

authorize the cremation, processing, and disposition of _________ ________ _ _

(hereinafter referred to as the "Deceased") ___ _ __________________ _ (La:it /mown addrtl$$ of <Jeceas6d)

Subject to the rules and regulations of Evergreen Memorial Park, you are hereby authorized and directed to

cremate or cause to be cremated the remains of the Deceased. Standard cremation time from droJ\ off to pick

up is 5 business days.

Funeral Home: Rubidoux Mortuary

Address: 6091 Mission Blvd., Riverside, CA 92509

Day of Cremation: ________ Date: ___________ Time: ___ _

Urn or Container Description: _ __________ Cremation Number: ___ _

.Disposition

I authorize lvergreen ·Memorial Park to do the followln91 ci..1,a., -·,

Release sa~ cr~mains to the possession and custody of the Funeral Home for

disposition as follows;...;.· _ ___ _________________ _

Release said cremains to famDy or responsible _person: __________ _

Interment of said cremains in Evergreen Memorial P1uk: __________ _

Scatter said c;remains at sea by Evergreen Memorial Park or its agent.

Ship said cremains via ________ _ ___ __________ _

To: Name ... __ . __________ Address -------------

OTHER ____________________ _... ____ _

IN-le understand that your servkes have been f\My completed when the remain leave Everoreen Memor~ Park and that you will ac1 as my agent for my_ accommodation only in carrying out these instructions.

Ibo Gramatior Procesa Pursuant to catifomla Health and Safety COde Section 7054.7 (b), the undersigned acknowledges readng and

understanclng the following stalement The human body bums with the casket. container or other material in the cremation dlamber. During the aematlon, the contents of the chamber may be moved to facilitate incineration. The chamber is compc&ed of ceramic or Olher material which disintegrates slightly during each cremation and the product of that disintegration is comingled with the cremated remains. Nearly all. of the contents of the cremation chamber, consisting of the cremated remains, disintegrated chamber material, and small amounts of residue from previous cremations, are removed together and crushed, pulverized, or ground to facilitate inumrnent or acatlering. Some residue remains In the cracks and uneven places d the chamber. Periodlcaly, the accumulation of this residue is removed and interred In a dedicated cemetery property, or scattered at sea.

When cremating Evergteen Memorial Park wil Hc.-c:iae reasonable effort• in keeping cremated remains separate. However, b~u .. it Is lmpo..a,le to guarantee or warrant that some bone particles °" the r.,.idue of one cremation c:oufd not poaibly be mixed with thole of another, I/We apecifically give eiqxaa permission for:

""'"-'- ..... , 1. _ _ _ _

2. ___ _

3. ___ _

4. ___ _

5. ___ _

6. ___ ~

,_ ·-·---,_ $poUS8

Children Parent

The crimation to take place lncluclng Incidental or inadvertent commingling of the remains wt1h realdue to prior gamatJoN tSoction 70$4. 7 Ca) (1) Califomla Health and Safety Codet. The proceulng of the remaina fndudlng cruahlng or grinding and lncldental commingling of the rem.int with reaklue from proceaslng other remains (Section 7064.1 Catifomfa Health and Safety Codel.

A person having the right to con~ disposition of crema~d remains ffliilY remov~ the remains in a durable container from the place of cremation or interment, pursuant to Section 7054.6 of the Health & Safety Code. If the cremated remains container ~nnot accommodate all of tile cremated remains of the deceased, 1he crematory shaH ~vlde a larger ~ntainer at no additional co~ or place the excess In a second .contailier that cannot ·easily come apart from the first, pursuant to Section 8345 of the Health & Safe~_ code.

All non-<XJmbustible materials such as metallic orthOpedic frr4:)lants, dental bridgewof1c. surgical pi',s, hinges, Jatches, nails, etc., will be separated and removed from the bone fragments by \risible or magnetic selection. The Crematory is aulhoriZed to recycle these metals through Altemative Solutions USA. a 501 (c)(3) Non-Profit Cremation Metal Remnants Disposition Program organized and oi:,eratad exclusively for charitabl8 purposes. I/We further authorize that if any items. other than the cremated remains of the Decea!led, are iecovered from the cremation chamber (lnltilll of thefollowlng): __ they shall be separated m;rn the cremated rvm.ains of the Deceased and d'tsposed a by the Crematory; or_ they shall be returned and placed tn the um or container holding the cremated remains. IMle understand thal if it is my intention to $3\le aey Items, it is my responsibility to remove them before cremation. NO REMAINS WILL BE ACCEPTED FOR CREMATION WTH ANY TYPE OF JEWELRY.

Mechanical or ra<ioaclive devices 1"1)1anted in the remains of the deceased (such as pacemakers, etc.) may create a hazard when placed in the c:remation chamber. I/We hereby warrant that said remains CONTAIN NO PACEMAKEA or other type of implanted mechanical or radioactive device or radioacti"8 nuclei. ·

I/We :agree to indemnify, release and hold Evergreen Memorial Park. its employees, agent•, and Its assigns. han11lus from env '°"· damages, liability or causes of action (Including attorneys' feu and e,cpenses of lti;atlont In conn~ion with the cremation and disposition of the aemated remaim of the O.Ceased. as authorized herein, or my failure to correctly Identify the remains of the Deceased, disclose the presence of any implanted mechanical or· radioactive devices, ot take possession of, or make · P9"'1anent arrangements for the disposition of such remalnt.

In the event auch remaioa h•v• not. been pennanently Interred or picked up by me or my agent deaignated for said purpose witttln twenty 420) days of this date, Evergreen Memorial ¥Irk is authorized to inter or QIUIO them to bo Interred In auch a manner II they deem advisable, indudlno commingrlflQ thereof by' interment in location or by manner with the remains of another person or persons.

IIW• warrant that all repre1entatlons ancl 1tatement5 macle herein are true and correct and make this atat•..-.nt to Induce Ever9....,. Memor-lol Park to cremate or cauM to be cremated the remal1tt of the Dec•aMd, and authorize Evergreen Memorlal Park to make dl1po1ltJon of the remolna a1 above Indicated.

The following persons authorize the cremation and disposition of the Decedent named above, and a~e that a ~~mile copy of this Authorization, or a copy of this Authorization with our electronic signatures, shall be as valrd as an ongmal.

Signatunt -------- ----...-------- RelaUonship __________ _ Address Phone# ______ ______ _

WITNESS; If this document is not signed before a staff member of the contracting mortuary, please attach a photocopy of photo identification with signature. or if no photo ID. then all signatures need to be notarized.

x _ _ _______________ _ Date _ _ ____ ___ , 20 ____ _

Funeral Homa Name/Address/Phone:

DECLARATION FOR DISPOSITION OF CREMATED REMAINS

I/ We hereby declare (my remains) or (the remains of) _ _______________ in Name of Person Arrangements are for

the possession of Rubidoux 1\/lort:uary 95 t .683.221 s 'will be cremated by Name· of Funeral Establishment and Telephone Number

__ E __ v_c_r_g_r_e_e_n __ c_r_e_m_a_t_o_r_Y __ 9_s_1_._6_B_3_._1_s_4_0 _____ and shall be disposed of in the Name of Crematory and Telephone Number

Following manner (note 1>: _________ ____ _ ___________ ____ _ Manner, Location and Other Details of Disposition

Attach additional pages if necessary

Name of person(s) with the legal right to control disposition 1note 2>: _ ________ ___ _

Signed

Signed

Signed

Signed

X Person(s} with legal right to control disposition or Self, if p rearranging

Person(s) with legal right to control disposition

Person(s) with legal right to control disposition

Person(s) with legal right to control disposition

Date

Date

Date

Date

Name of person(s) contracting for cremation services: ______ _________ _

Signed

Signed

X Date Person(s) contracting for cremation sel'llices

Funeral Director, Employee, or Agent for Funeral Establishment

Lie# - - - ----------------- ------ Date If Funeral Director

Note 1: See Health and Safety Code Sections 7054, 7054.6 , 7116. 71 17 for legal dispositions of cremated remains.

Note 2: See Health and Safety Code Sections 7100 for the list of person(s) with the legal right to control disposition of human remains.

IMPORTANT: Business and Professions Code 7685.2(b) requires Funeral Establishments to complete this form, provided by the Cemetery and Funeral Bureau, when making arrangements for cremation. Failure to complete this form may result In disciplinary action by the Bureau. This declaration does not replace the written authorization to cremate required by HeaHh and Safety Code Sections 7110 and 7111.

California Department of Consumer Affairs, Cemetery and Funeral Bureau www.dca.ca.gov/cemetery (Rev 3120031

NOTICE REGARDING CREMATED REMAINS

A person having the right to control disposition of cremated remains may remove the remains in a durable container from the place of cremation or interment. pursuant to Section 7054.6 of the Health and Safety Code.

If the cremated remains container cannot accommodate all cremated remains of the deceased, the crematory shall provide a larger cremated remains container at no additional cost. or place the excess in a second container that cannot easily come apart from the firsl pursuant to Section 8345 of the Health and Safety Code.

Original : To Be Retained by che Funeral Establishment ~ : Attach to Purchaser' s Copy of Contract

Signature

Signature

Signature

Signature

Decedent's Name:

You are contracting for cremation services specifically.

Due to doctors' schedule, crematory schedule, and the

Mortuary service schedule, we cannot nor will we, guarantee a

Date for the ashes to be returned to the family or agent thereof.

Therefore the person(s) making arrangements agree to

indemnify, release, and hold Rubidoux Mortuary,

its employees, agents and its assigns harmless from any delay

or causes of action (including attorneys' fees and expenses of litigation) in

connection with the cremation and disposition process.

Relationship

Relationship

Relationship

Relationship

Rubidoux Mortuary Kimberly Family Chapel FD 913 6091 Mission Blvd., Riverside, CA 92509

951-683-2215 951-683-3509 or 951-489-0607

Phone Fax Computer Fax

First Name of Decedent Middle Last (Family)

Date of Birth (MM/DD/YYVY) Age Sex Date of Death (MM/DD/YVYY) Hour

State of Birth Social Security Number Milital)' Service Marital Status Educat ion-Years Completed

Race Hispanic-Specify

CJ Yes Cl No

Occupation Kind of Business Yea rs in Occu pat lon

Residence-Street and Number or Location

City Qiuntv Zipoode Years in County State

Informant Name & Relationship Phone Number Mailing Address

Name of Surviving Spouse-Firnt Middle Last (MAI DEN)

Nan1e of Father-First Middle Last State of Birth

Name of Mother-First Middle Last (MAIDEN) State of Birth

Place of Death If Hospital, Specify On e:

CJIP CJ ER/OP CJ DOA

Street Address City & County

PLEASE Fill OUT AS MUCH AS POSSIBLE, ANY BLANKS WILL BE SUBMITTED AS 11UNKNOWN11