Duell, Jeffery S. BPHC 5/27/2021 10 : 13 : 35 AM PAGE 2/002 Fax Server
Couvnanwcealth of Massachusetts y
Registry of Vital Records and Statistics Slater file 42021 025898
•
DNN.-OSI T lON, REMOVAL.
0000557625 � OR TRANSPORTATION
Van,,R-3090701'_01,1 PERMIT..
Information necessary for the Certificate of Death has been completed for:
Decedent Name DUELL , JEFFERY S
Mace a/Death BRIGHAM AND WOMEN'S HOS 1'ITAL, BOSTON,MA
Date o/Death MAY 24,2021 Date a/Bird, JULY 27, 1968 Sex MALE
Residence 16 BABY LANE, HOOS IC K FALLS, NEW YORK 12090
• IT U.S.veteran,speei(i wct,/confliet(s)(most recent)
W NO
• Branch(/military(most recent) Rankatrr;aniz(ttion!au{/it(masn"ecem)
Date entered(most recent) Date Discharged(most recent) Service Num ber(most recent)
• Certifier DAVID BURIC, MD Lie# 274275
Addr. 75 FRANCIS STREET, BOSTON,MASS ACHUSEtTS 02115
luc m ediate Guise of Death
muunSYSTEM ORGAN FAILURE
This permit authorizes the following Funeral Senice licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee GEORGE FAGGAS Lit:it 5972
E Faciliy. FAGGAS FUNERAL HOME, INC.,WATERTOWN, MASSACHUSETTS
Di.spo.cition Type REMOVAL FROM STATE Da leq/Uisposition MAY 31,2021
Place/Address
PINE ViEW CREMATORY, 21 QUAKER ROAD,QUEENS BURY, NEW YORK 12804
Endorsements
Registry ofVital Records and Statistics Board of Health/Agent for: BOS1X)N
State Tracking ti 025898 Local Permit 4 B21025898
• Date MAY 27,2021 Date MAY 27,2021
Num e o f Igen( PAUL, S HOEMAKER
i hereby certify that the remains were disposed of in accordance with its tctmrs at the place and date below:
• Place olDisposition(Facility Name and Address) Signature
1714/ CrICIvivvrd ruvr\ Z"
�
• tit QV �0 f old Qrf✓l to�FA1 i1 y x
• Disposition Tppe ' Date n_fl)nposilii,, I Nance of Superintendent or.1 uthorized Dcc,.,nee:
Ce "4140 C91z17( (14eUtd WEE CENE/6'
Acceptance of Permit
Permits printed wit h the des ignat ion "E-PERM IT"may be accepted by a disposition facility prior to the completion o1'the Local Permit II.
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 informal ion and prior to registration
by the city or town clerk or registrar. Permits without the"E-PERM II'''dcsigriat ion 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 cremat ion clearance may have already been issued.Clearance status at the time the permit was printed is indicated at the top
of this form.
Aflcrconfirmation 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.
M
Public Health Law Sec. 4145(2b) - `
Receipt
I
Human remains of delivered on , 20
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#