Blumberg, Alvin 11 ; 7
R-309-08 Ole {iummnnwi attil of 5ttssat1 zs.ettI , Q060.9s
R-309-08 Vc,
No 006{}ss
OFFICIAL DISPOSITION, REMOVAL OR TRANSPORTATION PERMIT DISPOSITION, REMOVAL AND
(Issued under the provisions of Chapter 114,Section 45,General Laws,Tar.Ed.,as amended) TRANSPORTATION PERMIT
This parent eon be signed only by The agent at the of Health(or in towns where there is no Board of Health by the town 6erk1 of the city or
town in which the death occurred AFTER the FtLI sots of a esfectory certificate of death,printed•r typed to permanent black ink. This section to be returned immediate o e issuing City?we,properly endorsed
City/Town , . D.S ( / 7 20, ,✓ to 711) r`
A sf�pet)pry death certificate having fit,filed fo t (Office issuing permit)
t i City/Town of 7A::.
t Futt nam edent
tI I, 41 ""'C) ( � Name of Decedent„elf "'` I `4" '
who died or, I US War Veteran jj
ai date o d k 1 r
born on ,..." r ho resided at If a U.S.War Veteran,specify what war,organization,etc. /'-
Pr` date o both r ,,.."--'^""'�' ,
.` :.t`.,. cm p ,i 0—. ..-. t/ i
.Cr`ti' A—tr,"v---e 7 t
ENDORSEMENT
and who died Of•`'+,�� '" A C.,,, 1 "--" - .ss � '`. \- (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
t I Removal from: disposed of in accordance with its terms
name and address of era vat disposition
,x,A',,,' (,,y.--�._� rti--S.,,A,_,\..,, ( 'Af,,.YL'tiEnv„._('i-- at
t4 644
}�i 7�risposition atk) ''y (Name of cemetery or crematory) (City riots nj
\\\ name and address of cemetery or crematory jam
i 1 Transportation to: on OG�ii ("RI' '/q
3
name and address of immediate destination remains '
Permission is hereby given to: r, }—. , ) Final Dispositionfir ( .y ...
100
name of facility .0 '*� .-j, k-,, Certified by ;79
9r)G,k,__t,k,„,_\-- : (,,,,,INy.--1....t..._........\„,, (N._ -ONO, ‘_(,,, 1....... A---.
1 t �� address oft iii ,� ��� �� (Signature of 5uperimendent,cemetery or crematory)
yy ' fJ r
r Y
,r ,.-^� _ It there is no officer in charge,funeral director must sika,and return tins stub.