Chenier, Willaim Francis #- fn
Common wealtlhf 141assa`chusetts
e Registry of Vital Recon-&and Statistics State File# 2020 007511
DISPOSITION,REMOVAL
o000442490 OR TRANSPORTATION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name CHENIER , WILLIAM FRANCIS
PlaceofDeath TUFTS MEDICAL CENTER, BOSTON,MA
F Date ofDeath FEBRUARY 14,2020 Date ofBirth APRIL 14,1951 Sex MALE
w Residence 13 LUPINE LANE, QUEENSBURY, NEW YORK 12804
w If U.S.veteran,specify war/conflid(s)(most recent)
m NO
Branch ofm ilitary(most recent) Ranklorganimtion/outfU(most recent)
Date entered(mast recent) Date Discharged(most recent) Service Num ber(most recent)
Certifier DIANA 2HAANG, MD Lic# 275766
Addr. 800WASHINGTON STREET,BOSTON,MAS SACHUSETTS02111
F Immediate Cause ofDeath
ACUTE HYPDXIC RESPIRATORY FAILURE
U
This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
z
Funeral Licensee/Designee WIId1AM FSPENCER,JR Lic# 5 5
Facility. WM.F.SPENCER FUNERAL. SERVICE, BOSTON,MASSACHUSETTS
Dis o Date osition FEBRUARY 20,2020
Disposition Type REMOVAL FROM STATr of Disposition
o� Place/Address
a
PINE VIEW CREMATORY, 21 QUAKER \D,QUEENSBURY, NEW YORK 12804
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: BOSTO N
F
State Tracking# 007511 Local Permit# BOS2007511
Date FEBRUARY 17,2020 Date FEBRUARY 17,2020
Name ofAgent JAMES V.IMPRESCIA
z I hereby certify that the remains were disposed of in accordance with its terms atthe piam and date below:
F Place ofDisposiHon(Facili� Signature
Address) g 7
e �
p Disposition Type Date ofDisposi ' it Name ofSuperintm or d esign
Q.1:
Z170 to ��ri L..
Acceptance of Permit
Permits printed withthe designation"E-PERM IT"maybe accepted by a disposition facility priorto 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 priorto registration
by the city or town clerk or registrar. Permits without the"E-PERMIT"designation must contain a local permit number and date priorto
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#