Debanda, Rosario NEW YORK CITY THE CITY OF NEW YORK—DEkRT+ME"ITT 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 04:29 PM
156-20-024588
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -----------ceRnFicaTE riuMeeR
NAME First,Middle,Last AGE SEX I DATE I MONTH DAY YEAR
OF
Rosario Debanda 74 1 Female EVENT 04 12 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens Jamaica Hospital Medical Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
METHOD ❑ INTERMENT CREMATION
CERTIFIER OF ME/MLI Andrea Coleman
Sheryl Veliz DISPOSAL ❑ OTHER M.E.CASE#Q20016964
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY ��
DISPOSITION OF
Pine View Crematory 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) S TU J J N.Y.STATE LIC.#
APPLICANT .�
Thaddeus W. Baxter /WA o yAuthenticated 10227
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department �, '°o••.y /(/`
of Health and Mental Hygiene;or if it has been corrected, • • Q�
interlined or altered in any manner. Cty Registrar
FEE PAID$ 40.00 DATE 04 / 14 /2020 •• ••(� By Service Evital
VR21(REV.7/09) MM DD YYYY •••••V"
�'OF 41E'tI
Public Health Law Sec. 4145(2b) 0 13 5 6
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#