Jordan, Louis Commonwealth of Massachusetts —
Registry of Vital Records and Statistics State File# 2016 000362
DISPOSITION.
%'� ORTRANS TRANSPORTATION -' —
0000098167VAL
PERMIT
Foam R-30907012014
Information necessary for the Certificate ofDeath has been completed for.
Decedent Name JORDAN , LOUTS D
PlaceofBeath VILMA HOSPITAL 011WESTERN MASS,SPRINGFIELD, MA
Date ofDeath JANUARY 04,2016 Date ofBirth JUNE 15,1939 Sex MALE
ca Residence 40 LYON COURT,QUEENSBYIRY, NEW YORK 12804
00 If U.S.veteran,spec�J'woe cot(Itd fs)(most NCent)
P4 UNKNOWN
II Branch qfmillta'y(most recent) Ran Worgcaization'outfit(mostrecent)
Dale entered(maurecent) Date Discharged(most recent) Service NUM ber(mostrecent)
m Certfier SURESLIMAMIDAI.A, MD Dc# 241829
Add), 1400 S TATE STREET,SPRINGFIELD, SPRINGFII!Ll), MAS SACHUS ETTS 01109
aimmediate Cause of Death .�
CARDIOVASCULAR COLLAPSE
This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
Fe.neral Licensee/Designee KEVIN DAVIDSON �w is
o Facility. }L RTFORD TRADE SERVICE, L.LC,EAST HARTFORD,CONNECTICUT
7 Disposition Type BURIAL Date ofDi.Soosition JANUARY 08,2016
Place/Address
PINE VIEW CEMETERY, 53 QUAKER ROAD,QUEENSBUHY, NEW YORK 12804
Endorsements
Registry ofVital Records and Statistics Board ofHealth/Agent for: SPRINGFIELI)
State Tracking# 000362 Local Parma tl 16/000362
a Date JANUARY 06,2016 Date JANUARY 06,2016
Name ofAgeni HEL EN C AULTON-HARRIS
= I he reby certify that the remains were disposed of in accordance with its terms at the place and date below;
1.2., Place of Disposition(Facility Name and Address) Signature
Pine View Cemetery , ,�t;4-�iVl
d 21 Quaker Road
�80 X.
0 15ispasac�Fdn e ry Ny t Dateofl lsposition Name uperinten rAutharizedDesignee:
Burial 1 /8/1 6 Connie
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 apermit 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 priorto cremation. For ME-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.
Alter 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.
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