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Priest, Louis W QLF„) 4- I p 1 c Imp 1111E111 Commonwealth of Massachusts t Registry of Vital Records and Statistics State File# 2022 036686 DISPOSITION, REMOVAL 0000661592 OR TRANSPORTATION Form R-309 07012014 PERMIT Information necessary for the Certificate of Death has been completed for: Decedent Name PRIEST , LOUIS W Place of Death TUFTS MEDICAL CENTER,BOSTON,MA ., Date of Death JULY 29,2022 Date of Birth AUGUST 13,1955 Sex MALE z Residence 5 WESTLAND AVENUE,QUEENSBURY,NEW YORK 12804 w If U.S.veteran,specify war/conflict(s)(most recent) w NO • Branch of military(most recent) Rank/organization/ouYit(most recent) Date entered(most recent) Date Discharged(most recent) Service Number(most recent) ac Certifier BRADFORD GREAYES,MD Lic# 288805 R• Addr. 800 WASHINGTON,BOSTON,MASSACHUSETTS 02111 Immediate Cause of Death ` STROKE This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below: • Funeral Licensee/Designee ADRIANNE FAGGAS Lic# 7457 o Facility. FAGGAS FUNERAL HOME,INC.,WATERTOWN,MASSACHUSETTS w Disposition Type REMOVAL FROM STATE Date of Disposition AUGUST 02,2022 ok Place/Address a PINE VIEW CREMATORIUM,QUEENSBURY,NEW YORK 12804 Endorsements Registry of Vital Records and Statistics Board of Health/Agent for: BOSTON State Tracking# 036686 Local Permit# B22036686 w Date AUGUST 01,2022 Date AUGUST 01,2022 Name of Agent PAUL SHOEMAKER • I hereby certify that the remains were disposed of in accordance with its terms at the place and date below: Place of Disposition(Facility Name and Address) y�7�� Signature i t 4Acj—) C r L i-, 71 �vE uic P PP X ©• Disposition Type Date of Disposition Name of Superintendent or Authorized Designee: CrU,r%q gl t In I r Vi SV - 5T-4 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. V ,r I .i, .y 9`,i 0 d:- Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#