Fish, Dorothy R-309-10 01l a QIp mmn nunalt ll of B tt,1 oaril), tt o �� R-309-10 No. 107 i
..No 107
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 y
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/Town,properly endorsed
City/Town North Adams Date Aug, 9 20 13 to Health Department
(Office issuing permit)
A satisfactory death certificate having been filed for
Dorothy M. Fish City/Town of North Adams Mass.
Full name of decedent
who died on August 7, 2013 US War Veteran --- Name of Decedent Dorothy M. Fish
date of death
February 18, 1920 If a U.S.War Veteran,specify what war,organization,etc.
born on ,who resided at
175 Franklin Stree tot birth
North Adams, MA 01247 ENDORSEMENT
and who died of Dementia (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
I I Removal from: disposed(Qf in accordance 1wiiittthh��ittss[terms /` /�
name and address of original disposition at t{J 1QC i_ /C .a*R••_4e O(C, /AN
[?X Disposition at: Pine..View...Crematory. (Name of cemetery or crematory) (City/Town)
name and address of cemetery or crematory,
[ ]Transportation to: on -13-1"+
name and address of immediate destination of remains
Permission is hereby given to: Final Disposition
Flynn & Dagnoli-Montagna • Certified b �� .
7 4' Marshal ree ne of facility y gnature of Superintendent,cemetery or crematory)
....... .....
:ad
address of far'
, •
,( i •
--'L -- -ll.�C�i. -� If there is no officer in charge,funeral director must sign and return this stub.