Swears, Marilyn A. 1232
Commonwealth of Massachusetts
y Registry of Vital Records and Statistics State File# 2020 060295
DISPOSITION, REMOVAL
0000511147 •
.. - OR TRANSPORTATION
Form R-30907012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name SWEARS , MARILYN A
Place of Death BAYSTATE MEDICAL CENTER, SPRINGFIELD, MA
Date of Death NOVEMBER 20,2020 Date of Birth JANUARY 12,1933 Sex FEMALE
m Residence 79 OLD WEST ROAD,MOREAU, NEW YORK 12831
°
u If U.S.veteran,specty war/conflict(s)(most recent)
64 NO
o Branch ofmilitary(most recent) Rank/organization/outfit(most recent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
• Certifier THOMAS PRES TI, MD Lic# 276210
Addr. 759CHESTNUT STREET, SPRINGFIELD, MASSACHUSETTS 01199
Im m ediate Cause ofDeath
1.4 ACUTE HYPDXIC RESPIRATORY FAILURE
This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee JOSEPH D.CURRAN Lic# 6228
o Facility. CURRAN-JONES FUNERAL HOME,WEST SPRINGFIELD, MASSACHUSETTS
Disposition Type CREMATION Date ofDisposition NOVEMBER 24,2020
off. Place/Address
°
PINE VIEW CEMETERY, 21 QUAKER ROAD,QUEENSBURY, NEW YORK 12804
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: SPRINGFIELD
State Tracking# 060295 Local Permit# 20-060295
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Date NOVEMBER 23,2020 Date NOVEMBER 23,2020
a.
Name ofAgent HELEN CAULTON-HARRIS
• I hereby certify that the remains were disposed of in accordance with its tenns at the place and date below:
• Place of Disposition(Facility Name and Address) Signature
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p Disposition Type Date ofDis sition Name ofSuperintendent or Authorized gnee:
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Acceptance of Permit
Permits printed with the designation "E-PERMIT"may be accepted by a disposition facility prior to the completion of the Local Permit#.
This designation indicates that the death certificate has been electronically checked for completeness.In these cases,boards of health or their
designated agents will later assign a permit number upon subsequent verification of death certification information and prior to registration
by the city or town clerk or registrar. Permits without the"E-PERM IT"designation must contain a local permit number and date prior to
acceptance for disposal.
A cremation clearance from the Office of the Chief Medical Examiner is still necessary prior to cremation. For M.E.-certified death
certificates,the cremation clearance may have already been issued.Clearance status at the time the permit was printed is indicated at the top
of this form.
After confirmation of disposition,the disposition facility shall return the completed permit to the board of health agent as listed above and
retain a copy for their records.
Public Health Law Sec. 4145(2b) 0142 2 4
Receipt
Human remains of delivered on ./ '.r ; , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#,' `,