Winslow, John A. Jr. Commonwealth of Massachusetts
Registry of Vital Records and Statistics State File# 2020 003934
i' DISPOSITION,REMOVAL
0000438072 OR TRANSPORTATION
Form R-309 07012014 PERMIT
Information necessaryforthe Certificate of Death has been completed for:
Decedent Name WINSLOW JR, JOHN A
PlaceofDeath TIMBERLYN HEIGHTS NURSING AND REHABILITATION, GREAT BARRINGTON, MA
H DateofDeath JANUARY 26,2020 DateofBirth FEBRUARY 12,1960 Sex MALE
a
Residence 320 MAPLE AVENUE, GREAT BARRINGTON,MASS ACHUSEI'TS 01230
If U.S.veteran,specifywarleonflict(s)(most recent)
w NO
Branch ofmilitary(mostrecent) Rank/organization/outfit(mostrecent)
Date en tered(most recent) Date Discharged(most recent) Service Num ber(most recent)
Certifier JOSHUA MINT4 MD Lic# 217130
��- Addr. 38MULBERRY STREET,SUITE 204,NORTHAMPT'ON,MASSACHUSEI'TS 01053
Im m ediate Cause of Death
MYOCARDIAL INFARCTION
U
This permit authorizes the following Funeral Service licensee or Designee to remove,dispose or transport remains as listed below:
z
Funeral Licensee/Designee NIEGHAN L FINNERTY Lie# 7166
Facility. FINNERTY&STEVENS FUNERAL HOME,INC.,GREAT BARRINGTON,MASSACHUSETTS
F
Disposition Type REMOVAL FROM STATE Date ofDisposition JANUARY 28,2020
A° Place/Address
0
REGAN DENNY STAFFORD FUNERAL HOME,53 QUAKER ROAD,QUEENSBURY, NEW YORK 12804
Endorsements
F
Registry of Vital Records and Statistics Board ofHealth/Agentfor: GREATBARRINGTON
State Tracking# 003934 Local Permit# E-PERMIT
w Date JANUARY 27,2020 Date —
Nam eofAgent —
z I he reby certify that the remains were disposed of in accordance with its terms atthe pl ace and date below:
Place of Disposition(Facility Name and Address) Signature
a /':n a ✓.'e o✓ Cem e. te.ry ��
/✓V /2 rev
a x }Q-
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p Disposition Type Date ofDisposition No�eofSuperintende rAuthortzedDesignee:
f3teR-"i;[. G//o29 —f—
Acceptance of Permit
Permits printed with the designation"E-PERM IT"maybe 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 priorto
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.
Public Health Law Sec. 4145(2b) U 1 Q 3 6 3
Receipt
Human remains of _ delivered on , 20_F
(Pine ViedV Cemetery Representing the funeral home named on,burial permit
Official Funeral Directors Reg.or License