Baker Jr., Edward E ?sz
Commonwealth of Massachusetts
•,a Registry of Vital Records and Statistics State File# 2023 012724
DISPOSITION, REMOVAL
0000718544 .. OR TRANSPORTATION
Form R-309 07012014 PERMIT
Information necessary for the Certificate of Death has been completed for:
Decedent Name BAKER JR., EDWARD E
Place of Death CARE ONE AT LOWELL,LOWELL,MA
Date of Death MARCH 14,2023 Date of Birth FEBRUARY 26,1968 Sex MALE
w Residence 19 VARNUM STREET,LOWELL,MASSACHUSETTS 01850
°
If U.S.veteran,specify war/conflict(s)(most recent)
NO
o Branch of military(most recent) Rank/organcation/outfit(most recent)
Date entered(most recent) Date Discharged(most recent) Service Number(most recent)
Certifier MICHAEL G BERTOS,MD Lic# 160611
Addr. 20 RESEARCH PLACE,Suite 310,NORTH CHELMSFORD,MASSACHUSETTS 01863
Immediate Cause of Death
Lt ARTERIOSCLEROTIC HEART DISEASE
This permit authorizes the following Funeral Service Licensee or Designee to remove,dispose or transport remains as listed below:
Funeral Licensee/Designee ROBERT I DENSMORE Lic# NY 10910
° Facility. DENSMORE FUNERAL HOME,CORINTH,NEW YORK
Disposition Type REMOVAL FROM STATE Date of Disposition MARCH 17,2023
0
n. Place/Address
PINE VIEW CREMATORY,21 QUAKER ROAD,QUEENSBURY,NEW YORK 12804
Endorsements
Registry of Vital Records and Statistics Board of Health/Agent for: LOWELL
State Tracking# 012724 Local Permit# E-PERMIT
wa Date MARCH 16,2023 Date ---
a
Name of Agent ---
z I hereby certify that the remains were disposed of in accordance with its terms at the place and date below:
—0
Place of Disposition(Facility Nave arn Address) Signature
r l i C J i e ) rop/
Z 1 12‘44 eJ' (t A Z O'G X aa� 4/
o Disposition Type Date of Disposition Name of Superintendent or Authorised Designee:
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.
dap r� : s ,
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#