Disposition Permit Form Instructions

VS9e Form2 

  1. Boxes 1A, 1B and 1C you must enter the decedent's complete name
  2. Boxes 2 and 3, enter the Date of Birth and Death, respectively
  3. Box 4, 5A and 5B you must enter the sex, city and county of event, respectively
  4. On box 6, please retrieve this information directly from the death certificate boxes 26 and 27
  5. On box 7A, You must enter your name and address
  6. Box 7B must state " NONE ", since you are not a Licensed Funeral Home
  7. DO NOT SIGN OR DATE IT until you get to our office.   This document MUST be signed in front of our staff
  8. Boxes 9A enter the fee to issue a permit, which is $11.00
  9. DO NOT ENTER anything on box 9B or 9C
  10. Enter this address if you are filling the Disposition Permit in Berkeley
    • Berkeley City Health Department
    • 1947 Center Street, 1st Floor
    • Berkeley, CA 94704
  11. If dispostion is to occur in another county or district other than Berkeley, please use this box to specify what is the county/district name and address
  12. Box 10 is to be copied from the Certificate of Death box 39
  13. Boxes 11A, 12A, 13A, 14A or 15A MUST be retrieved from the data at the Certificate of Death.  You may use more than one box, if applicable.  For instance, if the person was cremated and scattered at the sea.  You have to use box 12A to enter the cremation information and box 15A to enter where the person's cremains was scattered.   You must remember also that this information, must be obtained directly from the Death Certificate box 40

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