Bondar, William 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 10, 2020 09:59 AM
EVENT:(CHECK ONLY ONE) N DEATH ❑SPONTANEOUS TERMINATION [I INDUCED TERMINATION """---""""1""""-" "56-20-"-"0'"-'--2-2475
CERTIFICATE NUMBER
NAME First,Middle,Last AGE I SEX I DATE MONTH DAY YEAR
OF (�)
William Bon 71 Male EVENT 04 07 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW PORK CITY
Queens 77-44 Austin St., 5E Forest Hills, NY 11375
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION
CREMATION APPROVED BY:
OF ME/MLI Anne Hoffa
Sean Kelly DISPOSAL ❑ OTHER M.E.CASE# Q20013716
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION OF (�)
Pineview Crematory Queensbury, NY DISPOSITION 04 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. 9807 Ascan Ave Forest Hills NY QDB03
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Thaddeus W. Baxter nat6XaA.thenbcated 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 �'•:r
of Health and Mental Hygiene;or if it has been corrected, •
interlined or altered in any manner. ;. �0
�. City Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 09 /2020 •� . • By_Service Ev"ital
MM DD YYYY AjyOF Nv$
Public Health Law Sec. 4145(2b) * - 013527
Receipt
Human remains of i delivered on + , 20:%
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#