Johnson, Muriel A3► 1
NEW YORK CITY THE CITY OF NEW YORK—DEPVTMENil OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
April 12,2020 05:09 PM 156-20-024641
EVENT:(CHECK ONLY ONE) IN DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Muriel Johnson 78 1 Female I EVENT 04 12 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens Jamaica Hos ital Medical Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER r CREMATION APPROVED BY:
CERTIFIER METOF D ❑ INTERMENT CREMATION J ME/MLI Michael Vaivao
Sheryl Veliz DISPOSAL ❑ OTHER 5`M.E.CASE# Q20017588
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR)
OF
DISPOSITION Pine View Cemetery and Crematory Queensbury, New York DISPOSITION 04 15 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
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE
N.Y.STATE LIC.#
APPLICANT ���/y
Steven Duca (,/,m Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department =��•�'`` "`�!.!F ./"�
of Health and Mental Hygiene;or if it has been corrected, • •y
interlined or altered in any manner. City Registrar v
FEE PAID$ 40.00 DATE 04 / 13 020 *••• . •� By_Service_Ev
/2 ital
VR 21(REV.7/09) MM DD YYYY �OF 0
Public Health Law Sec. 4145(2b)
jReceipt
i
I Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#