Johnston, Frank R-309-10 o'llP (nommoUwraifI of ilIf aiioFIrIU >jfa R-309-10 'NO
/� ��o. . t
No.......I.1.-.3 I o
OFFICIAL DISPOSITION, REMOVAL OR TRANSPORTATION PERMIT DISPOSITION, REMOVAL AND
(Issued under the provisions of Chapter 114,Section 45,General Laws,Ter.Ed.,as amended) TRANSPORTATION PERMIT
This permit 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 FIUNG and samptence of a satisfactory certificate of death,printed or typed In permanent black Ink. This section to be returned Immediately to the Issuing City/Town,properly endorsed
City/Town DAL r0A) Date ''S``)i-y / 20./.% to re i w ce r1i f c,
A satisfactory death certificate having been filed for (Office issuing permit)
T./CAiii.I< A D0/4ti S To A/ City/Town of PA E.,.TD Ai Mass.
{ Full name of decedent
who died on /jJ 4/ ,= �Y�t t .sZ.0.1 i US War Veteran NO Name of Decedent �P`r4��l� „To��S /tI
/ i �f�date of death
If a U.S.War Veteran,specify what war,organization,etc.
born on ........... �• date�of birthwho resided at
r& '��N S i /IL..Q
P-1,-•Trfv Oi 2,6 ENDORSEMENT
and who died of C.Git>r(:);2.()LJ l5LL'L,4,t 4�L,pit,'vv1 (To be filled in by cemetery or crematory official)
give immediate cause
Permission is hereby given for(check all appropriate boxes): I hereby certify that the body accompanying this permit was
I 1 Removal from: disposed of in accordance with its terms
name and address of original disposition
3 at iM�t� C4r4/mckli"iV
jf1 Disposition at: .......[..IA/L Zt Ew C�4��'rO R 1 .( .�ii t*j2.V t I (Name of cemetery or crematory) (City/Town)
name and address of cemetery or crematory ' / a`p I on I' i`1, 1( „g `4
[ I Transportation to: I W
name and address of immediate destination of remains
Permission is hereby given to: Final Disposition Gv il.$t.. i
Lr L/
name of facility Certified by
77/ n . az Y" T it f/5 L V .444 LJ I,Z0 I (Signature Superintendent,cemetery or crematory)
/addr9a of facility
<12 4(4/74-3--,1"/ If there is no officer in charge,funeral director must sign and return this stub.