Camino, Carlos 3K
NEW YORK CITY THE CITY OF N -DEPARTMf T OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF AL RECORDS
AND MENTAL HYGIENE PERMIT TO OSE OF OR TRANSPORT HUMAN REMAINS
April 13,2020 06:04 PM 156-20-025537
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION cERriFicnre riiiMaea
NAME First,Middle,Last AGE I SEX I DATE MONTH DAY (YEAR)
OF
Carlos Camino 64 Male EVENT 04 12 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens Long Island Jewish Forest Hills
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER r CREMATION APPROVED BY:
CERTIFIER METHOD D ❑ INTERMENT CREMATION J ME/MLI Melanie Gutteea
Amber Mallick DISPOSAL ❑ OTHER S`M.E.CASE# Q20017107
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF
DISPOSITION Pine View Crematory Queensbury, NY 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
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 Departments:• ``�!;fs `�p�
of Health and Mental Hygiene;or if it has been corrected,
interlined or altered in any manner. Cry Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 04 / )2020 00 of t o 00k By Service_EvitaI
1 Do
Public Health Law Sec. 4145(2b) 013,044
Receipt
Human remains of delivered on 20_
Pine View Cemetery Representing+the funeral home named on burial permit
Official Funeral Directors Reg.or License# `