Boncy, Simone 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 21,2020 09:11 AM 156-20-032183
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (AY)
Simone Boncy 85 Female EVENT 04 20 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens 8215 134th St,Apt 2D,Jamaica, NY 11435-1359
NAME OF PHYSICIAN OR MEDICAL EXAMINERS NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT IK CREMATION A
OF ME/MLInne Laib
Kristin Hord DISPOSAL ❑ OTHER M.E.CASE#Q20021008
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF (YYYY)
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 04 22 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.
FUNERAL NAME OF ESTABLISHMENT ADDRESS CITY AND STATE N.Y.STATE REG.#
ESTABLISHMENT Fox Funeral Home, Inc. 9807 Ascan Ave Forest Hills NY 00603
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) S J TU J .(�SFy".. J N.Y.STATE LIC.#
Thaddeus W. Baxter '� ,Authenbcated 10227
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
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NOTICE: This permit is not valid without the seal of the Department •,� °a• ^'���?�?� �/As/o&-
of Health and Mental Hygiene;or if it has been corrected, '. , iz�
interlined or altered in any manner. Cly Registrar v —
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 21 /2020 %••' ' •: By_Kathirav_elu_Kailayanatld
MM DD YYYY 4ryOFN 't
Public Health Law Sec. 4145(2b) � )
Receipt
Human remains of delivered'on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#