Clark, Vicary Commonwealth of Massachusetts
+,.a Registry of Vital Records and Statistics State File# 2017 012823
t'` OR TRANSPORTATION
0000200544
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name CLARK , VICARY GRATTON
Place of Death FALMOUTH HOSPITAL,FALMOUTH, MA
Date ofDeath MARCH 15,2017 Date of Birth JANUARY 17,1921 Sex FEMALE
w• Residence 16 WOODRISE,FALMOUTH, MASSACHUSETTS 02540
u If U.S.veteran,specify war/conflict(s)(most recent)
w NO
o Branch ofm ilitary(most recent) Rank/organization/outft(most recent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
• Certifier JONATHAN COSTA,DO Lic# 223964
• Addr. 100TER HEUN DRIVE, FALMOUTH, MASSACHUSETTS 02540
z Immediate Cause ofDeath
w PNEUMONIA
This permit authorizes the following Funeral Service Licensee orDesignee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee ROBERT P.QUEALY Lic# 50325
° Facility. QUEALY &SON FUNERAL HOME,ABINGTON,MASSACHUSETTS
c7, Disposition Type REMOVAL FROM STATE Date ofDisposition MARCH 17,2017
o.• Place/Address
PINE VIEW, QUEENSBURY, NEW YORK
Endorsements
Registry ofVital Records and Statistics Board of Health/Agent for: FALMOUTH
f State Tracking# 012823 Local Perm it# 17012823
w Date MARCH 16,2017 Date MARCH 16,2017
Name ofAgent MICHAEL C.PALMER
I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
• Place ofDisposition(Facility Name and Address) Sign r
• Pine View Cemetery
21 Quaker Rd. Queensbury NY but. t,
"? 41-4—e-r
c Disposition Type Date ofDisposition Name ofSuperintende uthorized Designee:
- Full Body 5/13/2017 Connie L. Goedert
Acceptance of Permit
Permits printed with the designation"E-PERMIT"may be accepted by a disposition facility prior to the completion of the Local Permit#.
This designation indicates that the death certificate has been electronically checked for completeness.In these cases,boards of health or their
designated agents will later assign a permit number upon subsequent verification of death certification information and prior to registration
by the city or town clerk or registrar. Permits without the"E-PERMIT"designation must contain a local permit number and date prior to
acceptance for disposal.
A cremation clearance from the Office of the Chief Medical Examiner is still necessary prior to cremation. For M.E.-certified death
certificates,the cremation clearance may have already been issued.Clearance status at the time the permit was printed is indicated at the top
of this form.
After confirmation of disposition,the disposition facility shall return the completed permit to the board of health agent as listed above and
retain a copy for their records.