Williams, Eliza 36S
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 14,2020 12:44 PM
___ 156-20-026166----------
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION El INDUCED TERMINATION -CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Eliza Williams 81 Female EVENT 104 10 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens New York Presbyterian Queens
CERTIFIER NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
OF ME/MLI Lauren Mecca
Annalisa Tolentino DISPOSAL ❑ OTHER M.E.CASE#Q2001 7577
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION Pine View CrematoryOF
(vvvv)
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.
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) SIGNgT�� N.Y.STATE LIC.#
Steven Duca �h^Jl1►(( '' 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
s••••••
of Health and Mental Hygiene;or if it has been corrected,
interlined or altered in any manner. City Registrar V —
VR 21(REV.7/09) FEE PAID$ 40.00
DATE 04 ) 14 )2020 *i •� �. * By Service Evital
MM DD YYYY OF N,:�V
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#