Alava, Alejandro - 3Q
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
April 13,2020 02:04 PM
156-20-025227
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION
CERTIFICATE NUMBER
NAME First,Middle,Last F1O2
SEX DATE MONTH DAY YEAR
OF (YYYY)
Alejandro Alava Male I EVENT 04 13 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW PORK CITY
Queens Queens Hospital Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT CREMATION
OF ME/MLI Kara Storck
Scoff Martin Baker DISPOSAL ❑ OTHER M.E.CASE#Q20017726
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION OF (YYYY)
Pine View Cemetery and Crematory Queensbury, New York DISPOSITION 104 17 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 AD D STATE DRESS CITY AND N.Y.STATE AEG.#
ESTABLISHMENT Fox Funeral Home, Inc. 9807 Ascan Ave Forest Hills NY 00603
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) ;TK?Mco(�Ijalca
N.Y.STATE LIC.#
Steven Duca Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE _ UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ��i'� �•• LIB,, �'
of Health and Mental Hygiene;or if it has been corrected, .•', 4°'i�s�
interlined or altered in any manner. Cry Registrar
•
VR 21 REV.7/09 FEE PAID$ 40.00
( ) DATE 04 / 14 /2020 .0 �•�•,* By Service Evital
--
MM DD YYYY Of NEY'I�
Public Health Law Sec. 4145(2b) - °•) 135 6.3
Receipt
Human remains of delivered on , 20
f*
Pine View Cemetery Represent g the funeral home named on burial permit
Official Funeral Directors Reg.or License#s,