Falkenbury, Jeffery 111
7 731
Commonwealth of Massachusetts
®l Registry of Vital Records and Statistics State File#DISPOSITION,REMOVAL
2016 016186
0000118086 L '. OR TRANSPORTATION
ION
Form R-309 07012014 PERMIT
Information necessary forthe Certificate of Death has been completed for:
Decedent Name FALKENBURY , JEFFERY E
Place of Death MASSACHUSETTS GENERAL HOSPITAL, BOSTON,MA
F Date of Death APRIL 10,2016 Date of Birth OCTOBER 21,1952 Sex MALE
w• Residence 119 WILTON -GANSEVOORT ROAD,GANSEVOORT,NEW YORK 12831
u If U.S.veteran,specifywar/conflict(s)(mast recent)
w NO
• Branch ofmilitary(most recent) Rank/organization/ouft(mostrecent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(mast recent)
m Certifier PAUL I.SIMMONS,MD Lic# 224030
• Addr. 50 S TANIFO RD STREET, SUITE 300,BO S TON,MAS SACHUS EFTS 02114
z Immediate Cause of Death
w PROFOUND HYPOTENSION WITH VA ECMO
U
This permit authorizes thr"llt.swing Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Desigri BRIAr' C MCKINNEY Lic# 50106
w Facility. MCCARTH`i MCIONN'FY&LAWLER FUNERAL HOME,FRAMINGHAM, MASSACHUSETTS
Disposition Type REMOO"-,FRO i M`8TATE Date of Disposition APRIL 12,2016
• Place/Address
c
PINEVIEW CREMATORY, 53 QUAKER ROAD,QUEENSBURY, NEW YORK 12804
Endorsem,
Registry ofVitai-.w_ %anstics Board of Health/Agent for: BOSTON
State Tracking# 016186 Local Permit# B16016186
• Date APRIL 11,2016 Date APRIL 11,2016
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:
0
Place of Disposition(Facili Name and Address Signature
• 1( Qua- p Q61 -poi
Pl+ �0 l;' �4�� uh X
p Disposition Type Date of Disposition Name of Superintendent or Authorized Designee:
airaVITOP 1 l) l6 C144810f 2 Sy-(*),`1
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.