Parker Sr., Gary Lewis * // 73c
11111 Cbm nwealth of Massachusetts
• it Registry Vital Records and Statistics State File# 2021 024377
DISP
VAL
0000555671
' OR TORANOSPORTATOION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name PARKER SR, GARY LEWIS
PlaceofDeath MASS ACHUSETTS GENERAL HOSPITAL, BOSTON,MA
• Date ofDeath MAY 15,2021 Date ofBirth NOVEMBER 16,1955 Sex MALE
14 Residence 14 BARRETT'S WAY, FORT ANN,NEW YORK 12827
°
k, If U.S.veteran,specify war/conflict(s)(most recent)
14 NO
o Branch ofm ilitwy(most recent) Rank/organization/outfit(mostrecent)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
• Certifier PAUL F.C1ARJER, MD Lic# 211099
��- Addr. 55FRU11 STREET,BOSTON,MASSACHUSETTS 02114
m ImmediateCauie`ofDeath
ga SEPSIS
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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 GEORGE FAGGAS Lic# 5972
o Facility. FAGGAS FUNERAL HOME,INC.,WATERTOWN, MASSACHUSETTS
h Disposition Type REMOVAL FROM STATE Date ofDisposition MAY 18,2021
off. Place/Address
PINE VIEW CREMATORY, 51 QUAKER ROAD,QUEENS BURY, NEW YORK 12804
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: BOS'IO N
• State Tracking# 024377 Local Permit# B21024377
14 Date MAY 18,2021 Date MAY 18,2021
Name ofAgent PAUL SHOEMAKER
• I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
o Place ofDis osition(Facry Name and Address) Signature
o i►/�l/ShV� �r� lyt0 01
x
c Disposition Type Date ofDisposition Name ofSuperintendent or Authorized Designee:
C -n4A i tor) S 126111
Acceptance of Permit
Permits printed with the designation"E-PERM IT"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.
Public Health Law Sec. 4145(2b) 14$0 3
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#