Herrick, Marilyn M Commonwealth of Massachusetts
a Registry of Vital Records and Statistics State File# 2023 005333
DISPOSITION, REMOVAL
0000708880 OR TRANSPORTATION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name HERRICK , MARILYN M
Place of Death 24 MALL ROAD,BURLINGTON,MA
E, Date of Death JANUARY 31,2023 Date of Birth FEBRUARY 10,1927 Sex FEMALE
PA Residence 24 MALL ROAD,BURLINGTON,MASSACHUSETTS 01803
wIf U.S.veteran,specify war/conflict(s)(most recent)
w NO
a Branch of military(most recent) Rank/organization/outt(most recent)
Date entered(most recent) Date Discharged(most recent) Service Number(most recent)
Certifier MARIE-HELENE ALMONOR,MD Lic# 257644
Addr. 45 DAN ROAD,CANTON,MASSACHUSETTS 02021
Immediate Cause of Death
CONGESTIVE HEART FAILURE
This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee ADRIANNE FAGGAS Lic# 7457
o Facility. FAGGAS FUNERAL HOME,INC.,WATERTOWN,MASSACHUSETTS
E.
Disposition Type REMOVAL FROM STATE Date of Disposition FEBRUARY 16,2023
w Place/Address
PINE VIEW CEMETERY,QUEENSBURY,NEW YORK
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: BURLINGTON
E.
State Tracking# 005333 Local Permit# E-PERMIT
w Date FEBRUARY 02,2023 Date —
o.
Name of Agent —
z I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
0
E. Place of n;, ,,citi (Facility Name and Address) Signature
X
o Disposition Type Date of Disposition Name�uperintenden�x.Authorize Designee:
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-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.
Public Health Law Sec. 4145(2b)
012969
Receipt
Human remains of ) delivered on L.• - , 20_3
li
r 'ne View Cemetery Representing the funeral home namedon burial permit
Official Funeral Directors Reg.or License#
•
9 B No.
HERRICK (i ) Lot
Address 3 Dixon Court Queensbury, NY 12804 \ Section No.
Owner Marilyn M. Herrick Plot Erie
Date 5/12/2010
Approx, 67 Superficial ft. @
Location Bounded on the North_ lay Vacant , East by Vacant , West by Dougher/
Var.ant and Smith by Path
Corner Posts
Remarks 793-3015
Deed No. (and changes) 3668
Payment Record Paid in full on 5/12/2010 ( $1 , 200.00)
Record of Interments 1_. 4 .
1 Robert H. Herrick (5/15/2010)
2 mc- c- ;\cfin 9-142
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Form No. 01
HERRICK (g)
NAME Marilyn HerrickAge: 96
LotOwner: Marilyn M. Herrick
Lot# Erie 9B Grave# 2
Case: Concrete
Died: 1 .31 .2 3 Interred:2.6.2 3
Funeral Home: Regan Denny Stafford
Cemetery: Pine View