Reed, Dawn Commonwealth of Massachusetts
•, , Registry of Vital Records and Statistics State File# 2016 036490
SITION, REMOVAL
0000150362 v` ./ OR TRANSPORTATION ORTATIION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name REED , DAWN M
Place ofDeath CRANEVILLE PLACE OF DALTON,DALTON,MA
F, Date ofDeath AUGUST 21,2016 Date ofBirth DECEMBER 27,1939 Sex FEMALE
°
Residence 265 MAIN STREET, DALTON,MASSACHUSETTS 01226
u If U.S.veteran,specify war/conflict(s)(most recent)
g4 NO
o Branch ofmilitary(most recent) Rank/organization/outfft(most recent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
• Certifier THOMAS J VAUGHAN, MD Lic# 49734
Addr. 33 NORTH STREET, DALTON,MASSACHUSETTS 01226
e Immediate Cause ofDeath
• CHRONIC HEART FAILURE, DIASTOLIC
This permit authorizes the following Funeral Service Licensee orDesignee to remove,dispose or transport remains as listed below:
F• uneral Licensee/Designee FREDERICK D DERY Lic# 50727
o Facility. J.EDWARD DERV, INC.,PITTS FIELD, MAS S ACHUS ETTS
• Disposition Type REMOVAL FROM STATE Date ofDisposition AUGUST 23,2016
a Place/Address
PINE VIEW CREMATORIUM, 21 QUAKER ROAD,QUEENSBURY, NEW YORK 12804
Endorsements
Registry ofVital Records and Statistics Board of Health/Agent for: DALTON
State Tracking# 036490 Local Permit# 36-2016
w Date AUGUST 23,2016 Date AUGUST 23,2016
NameofAgent DEBORAH J.MERRY
• I h e reby certify that the remains were disposed of in accordance with its terms at the place and date below:
F• Place of Disposition(Facility Name and Address) Signature
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c Disposition Type ate of Disposition N e ofSuperint dent or Authorized Designee:
• Grer.��--fin .grZyl f4 � 1,d�► �»�.��� G rerzato/'
Acceptance of Permit
Permits printed with the designation"E-PERM IT"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
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.