Benway, Barbara Commonwealth of Massachusetts
.�- Registry of Vital Records and Statistics State File# 2018 032787
0000309770
DISPOSITION,REMOVAL.
OR TRANSPORTATION '
Fort R-309 07012014 PERMIT
Information necessary for the Certificate ofDeath has been completed for:
Decedent Name BEVWAY , BARBARA JEAN
Place ofDeath FAIRVIEW COMMONS NURS AND REHABILITATION CENTER, GREAT BARRINGTON, MA
• Date ofDeath JULY 14,2018 Date of Birth MARCH 13,1952 Sex FEMALE
m Residence 20 STEWART AVENUE, SOUTHGLENS FAILS, NEW YORK 12803
°
w If U.S.veteran,specifywar/corflict(s)(most recent)
w NO
o Branch ofmilitary(most recent) Ran k/organization/outfit(most recent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
• Certifier JONATHAN B.GRENOBLE, MD Lic# 54069
• Addr. 20ELM STREET,PITTSFIELD, MASSACHUSETTS 01201
Immediate Cause of Death
wi RESPIRATORY FAILURE
U
This permit authorizes the following Funeral Service Licensee orDesignee to remove,dispose or transport remains as listed below:
• Funeral Licensee/Designee MEGHAN L FINNERTY Lic# 7166
o Facility. FINNERTY&STEVENS FUNERAL HOME,INC.,GREAT BARRINGTON,MASSACHUSETTS
Disposition Type REMOVAL FROM STATE Date of Disposition JULY 18,2018
A.• Place/Address
M.B.KILMER FUNERAL HOME,136 MAIN STREET, SOUTHGLENS FALLS, NEW YORK 12803
Endorsements
Registry ofVital Records and Statistics Board of Health/Agent for: GRFATBARRINGTON
E State Tracking# 032787 Local Perm it# 63-18
w Date JULY 17,2018 Date JULY 18,2018
o.
Name ofAgent MARIE Y.RYAN
• h e reby certify that the rema ins were disposed of in accordance with its terms at the place and date below:
o Place ofDisposition(Facility Name and Address) Signature
170 NIS NA OE INTO
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• '11 4"VN\11(1 riL 616 a 6%1 trit) x d
o Disposition Type Date of Disposition Name ofSuperintendent or Authorized Designee:
(FE 4)i, rJ 'Putts aliwublitg sfiJkkir
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
acc ptance 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.