Chabot, John it
R-309-10 OIiP Qlommnuwtatth of J'I: a art1uLPttB R-309-10 Z / I No. • 7-(a
- No... -1 ?-
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 dark)of the city or
town In which the death"ogre AFTER ththe{FILING and
acceptance 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 P „s� aid Date .. (..20 f . - to Pittsfield Health Dept.
A satisfactory death certificate having'� been filed for '�(leiktlen treat
.Q.1.\e 1 \ tMass.
vas :.fit' City/Town of Pittsfield,
Full name of decedent
(�/�
who died on 1! {` Ti. l US War Veteran Name of Decedent
nO[ i.J 5 iC`aFsoT
date of deat6L
�M�. ,_,.[�, a f If a U.S.War Veteran,specify what war,organization,etc.
r_iborn on 1 �l .. /t�/�)t ``—) ` 'of birth ie //�/t}�� ,who resided at p"
et
ENDORSEMENT
-� c on Ri S V3"/ �'I
and who died of ......c...l '..W..5.1.: ....�iw! `•`'2 `n��� �i.!""e T (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
[ ]Removal from: disposed of in accordancer' ith its terms�
name and address of original disposition / 4 �� / O r,(/,�
I. I,�S -hyri.L. Y) slo Arts luy at YI o cIIrre lrE/Wif V
[ isposition at �' t1 l,,(�:�C!(� � ���;(.'�.'�.� J( (Name of cemetery or crematory) �(t //J (City/Town)
name and address of cemetery oe cremdtory On T,„ ..,. vO t 1.,
I ]Transportation to: i [�
name and address of immediate deftinatiop of remains }t, ie 1 �y^ ,,f ^
Permission is hereby given to: f' Final Disposition 1 1 tl [/ C Il
17
,+ r • Certified b
e of facili � by
r7 9 co r`-i 0 C�\ r . Iii,�. t fvt (Signature of uperintendent,cemetery or crematory)
t V V address of farility-1' r t('1
• 4 ���� If there is no officer in charge,funeral director must sign and return this stub.