Morehouse, Joseph Wakely 12/22/2020 TUE 13251 FAX 121001/001
IV)
Commonwealth of Massachusetts
Registry of Yda!Rerords and Statistics Slate File g 2020 065809
s� DISPOSITION, REMOVAL
000031733$ 's...I OR TRANSPORTATION -
Pone R-30907012014 PERMIT
Information necessary forthe Certificate of Death has been completed for:
Decedent Name MOREHOUSE , JOSEPH WAKELY
Place ofDeath MASS ACHUSErn GENERAL HOSPITAL, BOSTON,MA
Date of Death DECEMBER 16,2020 Date of Birth JULY 27,1977 Sex MALE
a Residence 56 S AGAMORE STREET,GLENS FALLS,NEW YORK 12801
m /f U.S.veteran,specify war/cor fiict(s)(most recent)
a NO
o Branch of ml!!t
ary(most recent) Rank/organtZallon/oulJit(mostrecent)
Date entered(most recent) Date Dixharg ed(mast recent) Service Nu mber(mast recent)
a Certifier PAUL F.CURRIER, MD Lic/ 211099
▪ Addr. 55FRUTT STREET,BOSTON,MASS ACHUSETTS 02114
r Immediate Cause of Death
BACTERIAL PNEUMONIA
This permit authorizes the following Funeral Service licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensed Designee STARRBAKER Licr NY10159
o Facility. BAKER FUNERAL HOME,QUEFNSBURY, NEW YORK
Disposition Type REMOVAL FROM STATE Darr ofDLtpo.tltion DECEMBER 22,2020
a Place/Address
2 PINE VIEW CREMATORY, 21 QUAKER ROAD,QUEFNSBURY, NEW YORK 12804
o
Endorsements
Registry otViial Records end Seidetic' Board of HealiWAgeat fore BOSTON
y State Tracking• 065889 Local Permit# 1120065889
ig• Date DECEMBER 22,2020 Date DECEMBER 22,2020
NameofAgens PAUL SHOEMAKER
Z I hereby certify that the remains were disposed of In accordance wldsltatams atthe place sad date below:
o Place of Disposition(Facility Name and Addrev) Signatur/
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• zt (2 ke, ( .ru s'))►✓/ Neil ION
• 0(17 si:inn7),, e ---Date of-Disposition me`ofSupe'tn wide"or Authorized Designee:
• Cr-Pittc.f'r9t 12'2y— Zv 10 .mot - a.mat/L
Acceptance of Permit
Permits printed with the designation"E-PERMIT"may be accepted by a disposition facility p riorto the completion of the Local Permit b.
This desigtation 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 withoujthe"E-PERMIT"designation must contain a local permit number and datc 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) ``" 14323
Receipt
Human remains of delivered on - , 20—
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#