Bentley, Richard t
Commonwealth of Massachusetts
Registry of Vital Records and Statistics State File# 2017 021849
C t DISPOSITION, REMOVAL
0000212797 OR TRANSPORTATION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name BENTLEY , RICHARD L
Place ofDeath TUFTS MEDICAL CENTER., BOSTO MA
• Date ofDeath MAY 07,2017 Date ofBirth JANUARY 06,1955 Sex MALE
a• Residence 491 LAKE AVENUE, LOT#6,LAKE LUZERNE, NEW YORK 12846
u If U.S.veteran,specify war/conflict(s)(most recent)
a NO
• Branch of m ilitary(most recent) Rank/organization/outt(mostrecent)
Date entered(most recent) Date Discharged(most recent) Service Number(most recent)
• Certifier SHARANYA MOHANTY,MD Lic# 267448
• Addr. 800 WASHINGTON STREET,BOS TON,MAS S ACHUS ETTS 02111
Immediate Cause ofDeath
m SEPTIC SHOCK
This permit authorizes the following Funeral Service licensee or Designee to remove,dispose or transport remains as listed below:
FuneralLicensee/Designee ADRIANNE FAGGAS Lic# 7457
• Facility. FAGGAS FUNERAL HOME,INC.,WATERTOWN, MASSACHUSETTS
h Disposition Type REMOVAL FROM STATE Date ofDisposition MAY 10,2017
a Place/Address
PINE VIEW CREMATORY, 21 QUAKER ROAD,QUEENS BURY, NEW YORK 12804
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: BOSTO N
State Tracking# 021849 Local Permit# B17021849
w Date MAY 09,2017 Date MAY 09,2017
Name of Agent JAMES V.IMPRES CIA
I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
o
• Place ofDisposition(Facility Name and Address) Signature
7 Ft#4)01 (,Re nl iN t0 NA
Y 1
� X
71 QiitlieliA p po &j Ni. (13o/ l '
Disposition Type Date ofDisposition Name ofSuperintendentorAuthorized esignee:
(REtrili1 s I11 fri 1plizrsrof iNz- SEND
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.