Tucker, Sylvia 11
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
OCTOBER 06,2017 08:17 PM
156-17-040874
EVENT:(CHECK ONLY ONE) In DEATH ❑SPONTANEOUS TERMINATION 0 INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
)
OF
Sylvia Tucker 99 Female EVENT 10 06 2017
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens 68-37 Yellowstone Boulevard D21
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD INTERMENT ❑ CREMATION
OF ME/MLI
Michael Mencias DISPOSAL ❑ OTHER M.E.CASE#
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF (YYYY)
DISPOSITION Pine View Cemetery Queensbury, NY DISPOSITION 10 10 2017
THE CERTIFICATE OF DEATH HAVING BEEN FILED AS REQUIRED BY THE HEALTH CODE,AND ALL LAWS AND REGULATIONS
GOVERNING THE PREPARATION AND DISPOSAL OF HUMAN REMAINS HAVING BEEN COMPLIED WITH, PERMISSION IS
HEREBY REQUESTED TO DISPOSE OF THE REMAINS AS IDENTIFIED ABOVE.
NAME OF ESTABLISHMENT ADDRESS _CITY AND STATE N.Y.STATE REG.#
FUNERAL
ESTABLISHMENT Martin Hughes Funeral Home, Inc. 530 Narrows Road S Staten Island, New York 01114
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
APPLICANT ,yam/jam
Rocco P. Paccione �l/ Signature Electronically Authenticated 12747
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE R ' k, • :EQUES " A BOVE.
Al
NOTICE: This permit is not valid without the seal of the Department _,.�.', •.; .� 'Ile r�( I • • 14
of Health and Mental Hygiene;or if it has been corrected, g• ' .`�.•
interlined or altered in any manner. •") �y • ` ; City Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 10 / 06 /2017 * e i * By Dmitry Kopylenko
MM OD YYYY ?• •��0
�'Of NC\�