Cox, Norman 4.
R-309-10 �lit C ammanuirttl#!i of fitassaripititto j F3-309-10 No. 76(0
a
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/Town,property endorsed
City/Town Gt`.'eed 6OZA/L� Date .?.i"/, 20/:& to 2.qr C-J .t... 3 `...fi(CiLl 5
(Office issuing permit)
A satisfactory death certificate having been file for
A/,,eeih .'(/ c:1 )< , City/Town of 6- 6 ce.AA.1... f c-' 1„ Mass.
Full name of decedent
who died on �,.�/eb,f f,,..t b:,/. US War Veteran ...4'e :... .. Name of Decedent/{(�22 ./Z&/.V.. .,.....Z,,x-
. date of death
born on 4� , If/ ` who resided at If a U.S.War Veteran,specify what war,organization,etc..
ate of birth i 8_
• r %&ireief./1� .'lz,:z ..f..r21.I1-, ENDORSEMENT
and who died of —.' 4"1 &1/"r 4 I i-ie.. ,2 1441-i ive'•--+ (To be filled In by cemetery or crematory official)
give immediate ceu
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 �/+yy''' , 1
at I 3rV��W c cc ) 1l
[ I Disposition at: (Name of cemetery.. crematory) (City/Town)
name and address of cemetery or crematory
P,IQ 7.03
(a Transportation to: 2.)1!(�.1A2)442 ..Z:Z1:4/ edi. 147.4.... /,4,,C/V2:-Z/.../1,47 on , .1i ( ' 4 L
name and address of immediate destination of remains Final
I
Permission is hereby given to: Dispositionr�+ 164 (03
.......,: j4/ue%,-a,7 ,S.7 � ".s4,5.. // /✓2i2 / .t r1II dd
name of facility Certified by / • i,4..
yp y�/.7�� /t� �/"y.-" lq/ �-/- /ter. // ,, 1 (Signatu of Superintendent,cemetery or crematory)
'V re' /,t,LI.'7./2 C—J..�i 4: e1.'l.l�.... 7..tei ..z 7' j..aa.,Z'42 Jm
address of facility
'� If there is no officer in charge,funeral director must sign and return this stub.
Signature of Board of Health in towns re there to no Board of Health,of Town Clerk)