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R_309 01 e Tommaltmettlt "S of Awliar lawt i
R-3os No. .... .'J........... CA M
No. .......l.� Via...........
REMOVAL AND
OFFICIAL DISPOSITION, REMOVAL OR TRANSPORTATION PERMIT � DISPOSITION, -�
(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 M
or town in which the death oc N Ff(.ING,•anQ, Aar.C� Wry certificate of death,printed or typed in permanent black ink. Z
N �{j�*� T U / / This section to be returned immediately,properly endorsed i
City or Town.................................................................................Date Y.ki:4..1 19 ...714... u O
A satisfactory death certificate having been filed for to a ig **tTl7 _
. A '..
..................................../ f, ,'.t .1.^.......... r...........,11, Rs?.`*"A 6..................................... City or Town of...TC !�..OF ATHOL... ..........Mass.
Pull name of d—dent
who died on .......... � fit...... ! �.I.�*......................US War Veteran ........`71 Name of Decedent `. `. .Yt......r.:.:. �C>d1 tt SC''d 2
..,....,...
�,..- date of death
born on / "� � "' -� �� If a U.S.War Veteran,specify what war,organization,etc.
.................. f..:..........: '.... .............:';...K.....y~........,.......................... ,who resided at P Y g _
dr of birth f / (D
.......................... 1...........� ��; ' ......S..f.:1. . 5........ «,� ....................... -------------__._._:'. ......._...._,_._...._...._._._._._.
j ...........................................'y/,�....j..........I .`.............................................................................. ENDORSEMENT
andwho died of ............................................................................................................................... (To be filled in by cemetery or crematory official)
givo immediate cause
Permission is hereby given for(check all appropriate boxes): I h t t
hereby certify that the body ody accompanying this permit was
XRemoval from: ...........................•.�......... w1:.., /....... disposed of in accordance with its terms
me and a9dress of ongmal drsposit on
[ ]Disposition at: at .PI�. . .Y...f .'4C.......J �s!1'1^. W
- name and addoess of c m t t (Name of cemetery or crematory)y) (City or Town)
t
,-11 Transportation to: ....d...1. r «?�t l � �.ro+rf �, 1 IJ ? !�/r d ✓ ..
-�... r ...... on ..................... ........................................................................
name and address" unmedc desk ation of remains
Permission is hereby given to: / f Final Disposition ....r.................................
� ���, .iSf. r 1...... �dr ems,.. �� «r���'' -L
.. y
J�.................T n fa +.... Certified by ... (Signature
.',�,. t d t ... ..... t ) ............
ameof �ut�
>� Signa ure o uperin en ant,cemetery or crematory)
.......................................( .4....1....E ..... ......... ..4) •!. .............,..................................
d ty 5�i ant
If there is no officer in charge,funeral director must sign and return this stub.
................................gen.................................. ................................,....... N
i nature of Board of Hea]tb n t,or,in owns where there is no and of Health,of Town clerk
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