Sioui, Timothy Q.3
Commonwealth of Massachusetts
* b Registry of Vital Records and Statistics State File# 2017 035600
f DISPOSITION,REMOVAL
0000231452
OR TRANSPORTATION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name SIOUI , TIMOTHY EDWARD
Place ofDeath BRIGHAM AND WOMEN'S HOSPITAL,BOSTON,MA
F Date ofDeath AUGUST 04,2017 Date ofBirth DECEMBER 28,1964 Sex MALE
14 Residence 33 PUTNAM AVENUE, FORT EDWARD, NEW YORK 12828
°
u If U.S.veteran,specify war/conflict(s)(most recent)
w NO
° Branch o milit f ary(most recent) Rank/organization/outfit(mostrecevt)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
Y Certifier AMY BES SNOW,MD Lic# 233968
Addr. 75FRANCIS STREET,BOSTON,MASSACHUSETTS 02115
Immediate Cause ofDeath
w ACUTE MYELOID LEUKEMIA
This permit authorizes the following Funeral Service licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee FREDERICK J WOBROCK Lic# 6283
c Facility. MB IOLMER FUNERAL HOME,FORT EDWARD, NEW YORK
F
Disposition Type REMOVAL FROM STATE Date ofDisposition AUGUST 07,2017
0.. Place/Address
°
PINE VIEW CREMATORY, 21 QUAKER ROAD,QUEENS BURY, NEW YORK 12828
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: BOSID N
E.
State Tracking# 035600 Local Perm it# B17035600
o Date AUGUST 07,2017 Date AUGUST 07,2017
a
Name ofAgent JAMES V.IMPRES CIA
I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
Place ofDisposition(Facility Name and Address) Signature
X
pDisposition Type Date ofDisposition Name of Superintendent or Authorized Designee:
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.