Lupo, David It333
Conanonwe,'th of .achusetts
r, Registry of Vital Records and Statistics State File# 2023 017009
DISPOSITION, REMOVAL
0000724597 OR TRANSPORTATION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name LUPO , DAVID ---
Place of Death TIMBERLYN HEIGHTS NURSING AND REHABILITATION,GREAT BARRINGTON,MA
Date of Death APRIL 07,2023 Date of Birth JUNE 16,1943 Sex MALE
w Residence 320 MAPLE AVENUE,GREAT BARRINGTON,MASSACHUSETTS 01230
If U.S.veteran,specify war/conflict(s)(most recent)
w NO
Branch of military(most recent) Rank/organisation/outfIt(most recent)
Date entered(most recent) Date Discharged(most recent) Service Numher(most recent)
x Certifier JOSHUA MINTZ,MD Lie# 217130
Addr. 38 MULBERRY STREET,SUITE 204,NORTHAMPTON,MASSACHUSETTS 01053
Immediate Cause of Death
END STAGE DEMENTIA
This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee JOSEPH H ROY Lie# 6785
° Facility. BIRCHES-ROY FUNERAL HOME,GREAT BARRINGTON,MASSACHUSETTS
N Disposition Type REMOVAL FROM STATE Date of Disposition APRIL 11,2023
- Place/Address
c MB KILMER FUNERAL HOME,82 BROADWAY,FORT EDWARD,NEW YORK 12828
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: GREAT BARRINGTON
State Tracking# 017009 Local Permit# E-PERMIT
64 Date APRIL 11,2023 Date
a
Name of Agent —
. I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
E- Place of-Disposition(Facility Name and Address) Signature
z, paw?, 0011 X
Disposition Type Date of Disposition Name of-Superintendent or Authorize( esignee:
VeilvA>�ri Li/ 13173 a l PZTo Po a �i l4,1.1'
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)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#