Flint, William :State a.f Maine
Department of Health and Human Services IT SC@
Permit for Disposition of Human Remains
Distribution of Copies: g/ Place of Final Disposition ❑ Place Permit Issued
❑ Place of Death ❑ Issuing Clerk-Retain Until
Endorsement Received
1.FULL NAME OF DECEASED(First,Middle,Last,Jr.,etc.) 2.DATE OF DEATH(Mo., Day.,Yr.)
William Speyer Flint 11/10/2012
3.SEX 4.AGE 5.WAS DECEDENT Yes ❑ . 6.PLACE OF DEATH(City or Town) (State)
EVER IN U.S.ARMED
M 45 FORCES? No ® Durham Maine
7a.NAME AND ADDRESS OF FACILITY OR AUTHORIZED PERSON 7b.FUNERAL
Lindquist Funeral Home One Mayberry Lane Yarmouth ME 04096 ESTABLISHMENT 9541
LICENSE NUMBER
8.PERMISSION REQUESTED FOR:(Check All That Apply) ❑ Temporary Storage ❑ Burial ❑ Cremation ❑ Entombment
® Removal From State ❑ Burial at Sea ❑ Use by Medical Science El Disinterment
9. cm, Completed ❑ Report of I ® Medical Examiner's ❑ Application.or ❑ Facility/Physician letter for
AUTHORIZATION Death Death Release for Court Order disposition of fetal remains
FOR Certificate (Funeral Cremation,Removal for less than 20 weeks
PERMIT Directors from State,Burial At Disinterment gestation or product of
Only) 1 Sea,Use by Medical induced abortion of any
Science gestation
PERMISSION IS HEREBY GRANTED TO REMOVE AND DISPOSE OF
THE HUMAN REMAINS IDENTIFIED ABOVE .
10 Qti ATURE" OFA CLER R( e#11) �CITY OR TOWN� 10c.DATE SIGNED(Mo.,Day,Yr.)
4 '' 1&_s `1t., 1. _l_AL E.1c.,Y1\- / /-13'-/ ---
s11b. SUBREGISTRAR OF(List Municipality• 11c. DATE SIGNED(Mo., Yr.
1 NATURE OF SUBREGISTRAR Day, )
appointed by):
4
j.r r { '.�+! iii T c ` {L 4� t t'C� k,�!�J rjit-01, , .. s'y` "s 1� ° 7r , 1r, ' ,___ r s 7:, A .,
j , :,, ' ` is .,,
12. NAME OF CEMETERY OR VAULT 13. LOCATION (City or Town) (State)
❑ REMAINS WERE •
PLACED IN 14. SIGNATURE OF PERSON IN CHARGE OR MUNICIPAL OFFICIAL 15. DATE (Mo., Day,Yr.)
TEMPORARY
STORAGE
4
REMAINS WERE: 16. NAME OF CEMETERY,CREMATORY,MEDICAL 17. LOCATION (City or Town) (State)
SCHOOL,OR OTHER DESTINATION
❑ BURIED Pine View Crematorium QUeensbury, NY lR yO 1
® CREMATED 18. SIGNATURE OF PERSON IN CHARGE,MUNICIPAL OFFICIAL,FUNERAL 19. DATE (Mo.,Day,Yr.)
❑ ENTOMBMENT DIRECYflZ.,,Lg...J
,OR OTHER AUTHORIZED//
❑ BURIED AT SEA ÷ J. Nov. 14, 2012
20. NAME OF CEMETERY,OR OTHER DESTINATION 21. LOCATION(City or Town) (State)
® REMOVED FROM STATE Carleton Funeral Home Hudson Falls New York
22. SIGNATURE OF PERSON IN CHARGE,MUNICIPAL OFFICIAL,FUNERAL 23. DATE(Mo., Day,Yr.)
DIRECTOR,OR OTHER AUTHORIZED PERSON
4
24. ❑ Buried 25. NAME OF CEMETERY,OTHER LOCATION OR 26. DATE(Mo., Day,Yr.)
DISPOSITION OF CREMAINS: ❑ To Family RECIPIENT
El Scattered
❑ REMAINS WERE 27. NAME OF CEMETERY OR VAULT 28. LOCATION(City or Town) (State)
DISINTERRED
29. SIGNATURE OF PERSON IN CHARGE OR MUNICIPAL OFFICIAL 30. DATE(Mo., Day,Yr.)
4
Directions: The person responsible for the disposition must present four copies of this form to the municipal clerk or
subregistrar for signature. The permit is not valid until it has been signed by the clerk or subregistrar.
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