Simpson, William W-331
NEW YORK CITY THE CITY OF NEW YORK—i6EPJCRTMENT 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 01:04 PM 156-20-02258.4___
EVENT:(CHECK ONLY ONE) ®DEATH ElSPONTANEOUS TERMINATION ElINDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF
William Simpson 90 Male EVENT 04 06 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW PORK CITY
EVENT Queens 20 Continental Avenue Apt 3L, Forest Hills NY 11375
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT CREMATION
OF ME/MLI Benjamin Criss
Mikhail Pinkhasov DISPOSAL ❑ OTHER M.E.CASE# Q20014955
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY (EAARY)
OF
DISPOSITION Pine View 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 N.Y.STATE REG.#
FUNERAL
ESTABLISHMENT Fox Funeral Home, Inc. 9807 Ascan Ave Forest Hills NY 00603
APPLICANT
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
�(('l' ���/y
StevenDUca C) GGI.l.1/ Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.41
v
NOTICE: This permit is not valid without the seal of the Department
of Health and Mental Hygiene;or if it has been corrected, �"• •< -
interlined or altered in any manner. City Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 08 /2020
•' By ServiceEvital
••• _
MM DD YYYY
Of NEVI
Public Health Law Sec. 4145(2b) 013524
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#