Carrieri, Frank J70Jei ZJ j THZ! 141 U6 FAX 41344793C1 eery Funeral onts QUU1(6U1
LF I 1 5-11 to
Commonwealth of hitateaehGevrra mmelOIN
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Reglatry of Vital Reoerda and Stettslice Seats Fat d 2023 030916
VAL
t>aama4sa, t'• .• OR TRANSPORTATION
on.K40901e121114 PERMIT
Information necessary for the Certificate of Death has been completed fors
• Decadent Name CARRIERI , FRANK
hate;If Death HILLCREST COMMONS NEW AND REHABILITATION CENTER,PITTSFIEELD,MA
r DategfDectir JULY 03,2023 Date of Binh MARCH 03,1939 Sex MALE
in
16 R«.ravnte 169 VALENTINE ROAD,PITTSFIELD,MASSACHUSETTS 01201
"u ;fL',S.veteran,spvr1(y warico+J0 lrcr neon►ow)
W INO
a Branch ofm ilitaty(nevi went) Rank/t9 emetattan/oil f t(rnrut teteni)
Date entertwirmall re;etuu Date i lacharged(most recent) Semite Ntttnhdrprost went)
• Certifier SERWA GVIRAND,NI' IA It 23146119
Addr 16D VAL.L'TIN t ROAD,PITTSFIELD,MMASSACHUSETTS 01201
a Inttavdi us OW.V Death —
LI FAILURE TO THRIVE ---�I
Thla permit authorises the following Funeral Service Licence or Designee to remove,dispose or transport remain.es listed below;
R ranee/LlremseviDesignee FREDERICKDDERV Lirk 727
o
.. Facility. J.EDWARD DERV.INC.,PITTSFIELD,MASSACHUSETTS
w Dtspastrton 7}fie REMOVAL FROM STATE Date of Disposition JULY 07,2023
o Pfees iddrars
PINE VIEW CREMATORY.12 QUAKER ROAD,QUE1NSDLrRY,NEW YORK 12804
Endorsements
t.
Registry of Vital Raaorde end Itatiarka Board or Health/Anent revs PIT'F$Ft6LD
i State Trvuking?t 030916 Local Permit a L.PSRMIT
W Date JULY 06,2023 l Dell --
64
NOON,of Agent
, I hereby certify that the remain were diapeued of In aceurd.nce with Its terme it the place end data bedews
a -
Rye of Dispastr:on(F cllity Name and adrh ess) Stgnatate
I '
4 de- !Peva 6—i4'i c--L.a-rj
11/4/
o Disposition Type !Dort 0'1;m: 1i lop NOW reSkpfr'furen ens or Authorised Deeper
Cra. ao.d. 1z.�,z �a‘(mo.�� t�)� J
Aectptaats of Permit
Permits printed with the designation."E.PE RMlT"may be accepted by a diaposhion facility prior to the completion of the Lc:eC Permit 0.
Thia designation indicates that the death oertiricale ha.been eleotronloaily chocked fbr completeness,in ttsese cues,boards of health or their
designated agents will later assign a permit number upon subsequent verification of death certification Information and prior to fogistration
by the city or town clerk or registrar.Permit&without the PERMIT"designation mad contain a local permit number and date prior cr
acceptance to disposal
A cremation cteerem;e flvm the Offlee of the Chief Niediorl Examiner is still necessary prior to cremation, For M.L.-certified death
certificates,the cremation c}corecce may have already boots horsed.Clearance status at the time the permit was printed Is indicated at thtl top
of this form.
After confirmation of disposition,the disposition facility shall return the completed permit to the board of health agent as haled above and
retain a copy for their records
r- .. p t3}'
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#