Jones, Lynn I
The Commonwealth of flassachusetts
No.
OFFICIAL DISPOSITION, REMOVAL OR TRANSPORTATION PERMIT
(Issued under the provisions of Chapter 114,Section 45,General Laws,Ter.Ed.,as amended)
This pern t can be signed only by the agent of the Board of Health(or in towns where there is no Board of Health by the town clerk)of the city or
town in which the death occurred AFTER the FILING and acceptance of a satisfactory certificate of death,printed or typed in permanent black ink.
City/Town BURLINGTON Date September 20, 2011
A satisfactory death certificate having been filed for
Full name of
who died on Sept.20,2011 US War Veteran ----
date of death
born on Sept.24, 1950 ,who resided at
date of birth
1513 Pilot Knob Road
Fort Ann, Washington Co., NY 12844
and who died of End Stage Liver Disease
give immediate cause
Permission is hereby given for(check all appropriate boxes):
() Removal from: Queensbury, NY
name and address of original disposition
(X) Disposition at: Pine View Cemetery-Queensbury, NY
name and address of cemetery or crematory
O Transportation to:
name and address of immediate destination of remains
Permission is hereby given to:
Faggas Funeral Home
name of facility
551 Mt Auburn St., Watertown, MA 02472
ddres of cility
Signature of Board of Healtar.
n towns whet there is no Board of Health,of Town Clerk