Smith, Marilyn S 11111111111111 Commonwealth ofMassachusetts
Registry of Vital Records and Statistics State File# 2020 067383
DISPOSTTION,REMOVAL
0000519770 OR TRANSPORTATTON
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name SMITH , MARILYN S
Place ofDeath LANDMARK AT OCEAN VIEW, BEVERLY, MA
F, Date ofDeath DECEMBER 25,2020 Date of Birth JANUARY 28,1927 Sex FEMALE
w Residence 3 ES S EX STREET,BEVERLY, MAS S ACHUS ETTS 01915
m If U.S.veteran,specify war/conflict(s)(most recent)
w NO
a Branch ofmilitary(mast recent) Rank/organization/outfit(most recent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
a Certifier JULIANNE HAZARD, NP Lic# 2283625
• Addr. 800 TURNPIKE STREET, SUITE 300,N ANDOVER, MAS S ACHUS ETTS 01845
• Immediate Cause ofDeath
wi CARDIOPULMONARY ARREST
This permit authorizes the following Funeral Service licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee ROBERT B.PORTER Lic# 5693
° Facility. WHITTIER PORTER FUNERAL HOME,IPSWICH,MAS S ACHUS ETTS
Disposition Type REMOVAL FROM STATE Date of Disposition DECEMBER 30,2020
a Place/Address
• PINEVIEW CEMETERY, 21 QUAKER ROAD,QUEENS BURY, NEW YORK 12804
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: BEVERLY
State Tracking# 067383 Local Permit# E-PERMIT
w Date DECEMBER 29,2020 Date
a
Name ofAgent --
z I hereby certify that the remains wen disposed of in accordance with its terms at the place and date below:
• Place of Disposition(Facility Name and Address) Signature
▪ Pine View Cemetery
x• 21 Qauker Rd x - I
Oueensbury, NV 1 R04 °
o Disposition Type Date of Disposition Name ofSuperintendent re thorized Designee:
Burial 12/30/2020 Connie Goedert
Acceptance of Permit
Permits printed with the designation"E-PERM IT"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-PERMIT"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.
i
Public Health Law Sec. 4145(2b)
012833
Receipt
Human remains of ;'‘, delivered on +.``- , , 20 ,
me View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
SMITH
NAME Marilyn S. Smith Age: 93
61
Lot Owner:
Mr & Mrs Andrew Smith
Lot# Oneida 74-B Grave# 1
Case: Concrete
Died:12/25/2020 Interred:12/30/2020
Funeral Home: Whittier. .Porter FH
Cemetery: Pine View