Tanner, Vera R-309-10 lilt C1Iommonwealtl? of Jll: tt,s,�ttrllu�srtts R-309-10 No. 313
No.
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 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/T tr.),properly end rayd
City/Town..- .1.S,1.a.-:4,-: C>y6 '7G>`-J Date 20 to` 401r,. Cr., 12 7
I (Office issuing permit)
A satisfactory death certificate having been filfor /��A L 1 ,
Yt'R�P...... i� I ' ( City/Town of . �L� G�'�'��/ Mass.
Full name of decedent `1 ,�nAtt7
who died on �"0. Name of Decedent Y t1 (A C+�1+-a-✓
>7µf$, „ ,...t..Q..I. US War Veteran .Ittu°
date of death
born on J l/.) Zi. If a U.S.War Veteran,specify what war,organization,etc.
...t� y,g ,who resided at
date of birth I
iSI Chil.S+ n...11 i I kocsti
eptvccip,,c,r f) ffh MA ENDORSEMENT
and who died of ...AU.iti.p(:µ,.1st (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 accordance with its terms///���
name and address of original disposition PotuE(ht / Vhr`
f , fa 1� ee�� /r��1�Q��(� at �/ ` L1 vim_.
[pf Disposition at: ....PinA......ji.C.t.✓ Cif c.,:la.:f,wt ,jj �S�IEl2115hk P'(. 1.G2V.9 (Name of cemet or crematory) (City/Town)
name and address of�efery or crematory VL1
[ ]Transportation to: on lJ
name and address of immediate destination of remains /—C.'
Permission is hereby given to: i, Final Disposition
` f .7
�/
name of facility Certified by
-
�G Rain S� /' ` 4)' ! + zP32 (Signature of perintendent,cemetery or crematory)
ldt7 �w� rl t� /�t
address of facili
If there is no officer in charge,funeral director must sign and return this stub.