Silva, Tomas r ,, '3 7 1)
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 16, 202010:29 AM 156-20-028055
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION ceanl=icnTe NUMeea
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Tomas Silva 88 Male EVENT 04 10 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW PORK CITY
EVENT Queens New York-Presbyterian Queens
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
METHOD ❑ INTERMENT I� CREMATION Adrienne Licking
CERTIFIER OF ME/MLI
Paola Reveco DISPOSAL ❑ OTHER M.E.CASE#Q200188355
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
R)
OF
DISPOSITION Pine View Crematoy Queensbury, NY DISPOSITION 04 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 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) I S TU EJ J N.Y.STATE LIC.#
APPLICANT
Thaddeus W. Baxter o, IlyAuthenticated 1 10227
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED 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, '
interlined or altered in any manner. City Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 16 /2020 ' ••:•:•• By.Service_Evital
MM DD YYYY OF
Public Health Law Sec. 4145(2b) ` . 3 5 R 0
Receipt
i
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License