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Turner, Roger • e Commonwealth ofMassachusetts •,a Registry of Vital Records and Statistics State File# 2017 027441 DISPOSITION,REMOVAL 000o2t9958 OR TRANSPORTATION Form R-309 070,12014 PERMIT Information necessary for the Certificate of Death has been completed for: Decea`'entJUame TURNER , ROGER A. Place of Death BERKSHIRE MEDICAL CENTER, PITTSFIELD, MA E. Date ofDeath JUNE 12,2017 Date of Birth NOVEMBER 17,1945 Sex MALE i4• Residence 2646 COUNTY ROUTE 12,WH EHALL, NEW YORK 12887 JfUS.veteran,specg7ywar/contflia(s)(most recent) i4 NO a Branch of militwy(most recent) Rank/organization/o 14/it(most recent,) Date.entered(most recent) Date Discharged(most recent) Service Num ber(most recent) Certifier YEWANDE ADEPOJU, MD Lic# MA260599 Addr. 725NORTH STREET, PITTSFIELD, MASSACHUSETTS 01201 immediate Cause of Death ACUTE RESPIRATORY FAILURE This permit authorizes the following Funeral Service licensee or Designee to remove,dispose or transport remains as listed below: Funeral Licensee/Designee ROBERT E.DWYER, SR Lic# 4780 © Facility. DWYER FUNERAL HOME,INC.,PITTS FIELD, MASSACHUSETTS Disposition Type REMOVAL FROM STATE Date of Dispo.sition JUNE 14,2017 • P. Place/Address PINEVIEW CREMATORIUM, QUEENS BURY, NEW YORK Endorsements JReecordmLStatiaties Baard•ofliealth/Agentfor: NTISFEELD State Tracking# 827441 Local Permit# Y.-PERMIT a Date JUNE 14,2017 Date o. Name of Agent --- I hereby certify that the remains were disposed of in+aceoradance with4tsterwn at the place and date below: — Place of-Dispositions(Fardlt Nance ,4 res), Signature pr E 4,6111kri tiih z II V kit� Rto 0111. 12(G X ,.s Disposition Type Date ofDisposition Name ofSuperintendent or Authorized Designee: erkoirtrzet 41 ffir1 ttt frro Acceptance of Permit Pt-ta is printedwith the designation `•E-1 ERMTI"'may he acuepted 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-townclerk or registrar.Pewrote without ut the'"F-PERMIT"designation mast 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 atready 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.