Northrup, Karen Commonwealth of Massachusetts
11111111111111111
r Registry of Vital Records and Statistics State FileDISPOSITION,.REMOVAL
li 2016 052581
0000173745 •
`11.-'••" OR TR ANTSPORTATlON
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name NORTHRUP , KAREN ANN
Place ofDeath BRIGHAM AND WOiEN'S HOSPITAL, BO S TO N,MA
Date ofDeath NOVEMBFR30,2016 Date of Birth JANUARY 05,1945 Sex FEMALE
ka Residence 51 DEAN ROAD,HUDSON FALLS, NEW YORK 12839
.r if U.S.veteran,spec ti:wan''conflia(s)(most recent)
ra
NO
Branch o m flit (most recent) Rank o of military r rgaai=atfonloulfit(mostrecen)
Date entered(most recent) Date Discharged(most recent) Service.Number(mastrecent)
O Certifier ALIST6R MARTIN, MD Lie it 264201
.4ddr•. 7SFRANCIS STREET,I3OSTOti,MASSACHUSETTS 02115
Immediate Cause ofDeath
W RESPIRATORY FAILURE
This permit authorizes the following Funeral Service licensee orDesignee to remote,dispose or transport remains as listed below:
Funeral Licensee'Designee GEORGE FAGGAS Lich 5972
c Facility. FAGGAS FUNERAL HOME, INC.,WATERTOWN, MAS SACHUSETTS
h Disposition Type REMOVAL FROM STATE Date ofD/sposition DECF.IMIBER 03,2016
Place.Addrzss
PINE VIEW CREMATORIUM, 21 QUAKER ROAD,QUEENSBURY, NEW YORK' 12804
Endorsements
Registry ofVital Records and Statistics BoardofHealth/Agent for: BOSTON
State Tracking 4 052581 Local Permitr B16052581
w Date DECEMBER 04,2016 Date D EC.E%-IBER 05,2016
a.
Nameof.4gent JAMES V.EMPIRES CIA
I hereby certify that rheremainswere disposed of in accordance with its terms at thc pl ace a od date be low:
Place ofDisposition(Facility Name and Address) Signature
29 Q"Alt' Cod)
o Disposition:jppe Date ofDisposition f Name ofSuperiniendent or.4uthort_ed Desi ee:
Acceptance of Permit
Permits printed with the designation"F_-PERMIT"may be accepted by a disposition facility priorlo the completion of the Local Permit Ii.
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 priorto registration
by the city or town clerk or registrar. Permits without the"E-PERM IT"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 atthe 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.
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