Molina, Joanie A. -. -# 31�
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
April 09,2020 05:04 PM
156-2 0-02191__1__________
EVENT:(CHECK ONLY ONE) N DEATH ❑SPONTANEOUS TERMINATION El INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Joanie A Molina 55 1 Female EVENT 1 04 06 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITYTManhattan New York Weill Cornell Medical Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION
CREMATION APPROVED BY:
�
OF ME/MLI Cheryl Luning
Melanie Koren DISPOSAL ❑ OTHER M.E.CASE# M20014359
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION OF (YYYY)Pine View Crematory Queensbury, New York DISPOSITION 104 11 2020
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
FUNERAL N.Y.STATE REG.#
ESTABLISHMENT Fox Funeral Home, Inc. 1 9807 Ascan Ave Forest Hills NY 00603
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.V.STATE LIC.#
Thaddeus W. Baxter na Authenticated 10227
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ��•r +o 'LI
of Health and Mental Hygiene;or if it has been corrected, Yo
interlined or altered in an manner.
1:. City Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 L 08 /2020 •� . • By_Service_Eyital
MM DD YYYY gn OF Nay
Public Health Law Sec. 4145(2b) - 01 3 5?6 '
I
Receipt
Human remains of delivered on Li 20—
f
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#