Fosbrook, Leonard S
Commonwealth of Massachusetts
, Registry of Vital Records and Statistics State File# 2018 010397
DISPOSITION, REMOVAL,
0000278752 • OR TRANSPORTATION
Form R-30907012014 PERMIT
Information necessary forthe Certificate of Death has been completed for:
Decedent Name FOSBROOK , LEONARD ARTHUR
Place of Death BRIGHAM AND WOMEN'S HOSPITAL,BOSTON,MA
F Date of Death FEBRUARY 27,2018 Date ofBirth S EPT EMBER 20,1945 Sex MALE
w• Residence 101 NORTHWEST ROAD,QUEENS BURY, NEW YORK 12804
°
If U.S.veteran,specify war/confict(s)(most recent)
w NO
o Branch ofm ilitary(most recent) Rank/organi=ation/outfit(most recent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
„ Certifier ANDREW S ILAPAS WAN, MD Lic# 271993
• Addr. 75 FRANCIS STREET, BOSTON,MAS S AC HUS ETTS 02115
Immediate Cause of Death
w SEPTIC SHOCK
This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee ROBERT P.QUEALY Lic# 50325
o Facility. QUEALY &SON FUNERAL HOME, ABINGTON,MASSACHUSETTS
Disposition Type REMOVAL FROM STATE. Date of Disposition MARCH 06,2018
a Place/Address
PINE VIEW CREMATORY, QUAKER RO%L,QUEKNSBURY, NEW YORK 12804
Endorsements
Registry ofVital Records and Statistics Board of Health/Agent for: BOSTON
State Tracking# 010397 Local Permit# B18040397
w Date MARCH 01,2018 Date MARCH 01,2018
Name of Agent JAMES V.IMPRESCIA
I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
Place of Disposition(Facility Name and Address) Signature
z 1 avr .L o itQ "�
flotttsgv � gx
• Disposition Type Date of Disposition Name ofSuperintendentorAuthori_ed Designee:
(Rft►iats)r) (tWj:s SENPt`r
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.