Chase, RonaldCommonwealth ofMassaehusetts
+ a Registry of Vital Records and Statistics 2019 046941
IStateFile#
DISPOSITION, REMOVAL
OR TRANSPORTATION
0000412974
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name CHASE, RONALD JAMES
PlaceofDeath HH.LCREST COMMONS NURS AND REHABILITATION CENTER, PITTSFIELD, MA
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DateofDeath OCTOBER20, 2019 Date of Birth AUGUST 27, 1952 Sex MALE
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Residence 210 BLUE BIRD ROAD, MOREAU, NEW YORK 12803
If U.S. veteran, spec#y war/conflic7(s) (most recent)
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Branch ofmilltary (most recent) Ran k/organization/otufit(mostrecent)
Date en tered(most recent) Date Discharged (most recent) Service Num ber(most recent)
Certifier BARRY J. LOBOVITS, MD Lic # 39562
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Addr. 163 S OUTH S TREET, SUITE #3, PITTS FIELD, MAS S ACHUS ETTS 01201
Im mediate Cause of Death
CARDIOPULMONARY ARREST
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This permit authorizes the following Funeral Service licensee or Designee to remove, dispose or transport remains as listed below:
Funeral Licensee/Designee FREDERICK D DERY Lic # 50727
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Facility. J. EDWARD DERY, INC., PITTS FIELD, MAS S ACHUS ETTS
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Disposition Type REMOVAL FROM STATE Date of Disposition OCTOBER22,2019
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Place/Address
PINE VIEW CREMATORY, 21 QUAKER ROAD, QUEENSBURY, NEW YORK 12804
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Endorsements
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Registry of Vital Records and Statistics
Board of Health/Agent for: PITISFIFLD
State Tracking # 046941
Local Permit # E-PERMIT
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Date OCTOBER 22, 2019
Date
NameofAgent —
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I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
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Place of Disposition (Facility Name and Address)
Signature
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Disposition Type
Date ofDisposition
Name ofSupaintendentorAuthortzedDesignee:
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Acceptance of Permit
Permits printed with the designation "E-PERMIT"may be 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 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)
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Receipt
Human remains of
Pine View 06metery
Official
- : delivered on
Representing the funeral home named on
Funeral Directors Reg. or License #
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