Brown, Stennet P- V
NEW YORK CITY THE CITY OF NEW YORK—D8*AQ TMbNT 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 06:59 PM
EVENT:(CHECK ONLY ONE) ®DEATH ElSPONTANEOUS TERMINATION ❑INDUCED TERMINATION 156-20-024716
CERTIFICATE NUMBER
NAME First,Middle,Last AGE I SEX DATE MONTH DAY YEAR
Stennet Brown OF (YYM82 Male EVENT 104 12 2020
PLACE OF NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK :=BOROU7GH
ueeQueens Hospital Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER
CERTIFIER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
OF ME/MLI Lauren Mecca
Marina Murdakhayeva DISPOSAL ❑ OTHER
`M.E.CASE#Q20018192
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,NY 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.
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) SI^GN�P—IMC;AtJUM
N.Y.STATE LIC.#
Steven Duca V Signature ElectronicallyAuthentiwted 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE _ UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department �•�� �!• /�
of Health and Mental Hygiene;or if it has been corrected,
interlined or altered in any manner. • Cry Registrar
VR21(REV.7/09) FEE PAID$40.00 DATE 04 ) 16 )2020 '•••�•••.•* By_Serv_ice Eyital
MM DD YYYY rhyme
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#