Dickenson, Carole Commonwealth of Massachusetts
Registry of Vital Records and Statistics State File# 2017 046366
DISPOSITION,REMOVAL
0000246594 OR TRANSPORTATION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name DICKENSON , CAROLE R
Place of Death REDSTONE REHABILITATION &NURSING CENTER, EAST LONGMEADOW, MA
F Date of Death OCTOBER 16,2017 Date of Birth JULY 03,1953 Sex FEMALE
w• Residence 83 HOPE FARMS DRIVE, AGAWAM, MASSACHUSETTS 01030
4' If U.S.veteran,specify war/conflict(s)(most recent)
w NO
• Branch ofm ilitary(most recent) Rank/organi._ation/outfit(most recent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
• Certifier FAHIM KAZI, MD Lic# 222714
• Addr. 300 STAFFORD STREET, SUITE 200,SPRINGFIELD, MASSACHUSETTS 01104
z Immediate Cause of Death
w CONGESTIVE HEART FAILURE
This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee FRANK A. FORASTIERE Lic# 5408
w Facility. FORASTIERE SMITH FUNERAL HOME,EAST LONGMEADOW, MASSACHUSETTS
7, Disposition Type CREMATION Date ofDisposition OCTOBER18,2017
P.• Place/Address
PINEVIEW CREMATORY, 21 QUAKER ROAD,QUEENS BURY, NEW YORK 12804
Endorsements
Registry ofVital Records and Statistics ' Board of Health/Agent for: FASTLONGMFADOW
State Tracking# 046366 Local Perm it# E-PERMIT
w Date OCTOBER 17,2017 Date
a
Name ofAgent ---
z I h e reby certify that the remains were di sposed of in accordance with its terms a t the place and date be low:
F• Place of Disposition(Facility Name and Address) Signature
• Pihe v;6.-t.J e 1Ninw.,10^'
a Z1 Qw4. / 1� C 4.4 bpfif i
12004) X
c Disposition Type Date of Disposition Name o uperintendent orA thorized Designee:
u
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-PERM IT"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.