Pecorini, Andrew .L # 3i q
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 15, 2020 01:59 PM
156-20-027304
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -----------CERTIFicarE NUMBER
NAME First,Middle,Last AGE I SEX I DATE I MONTH DAY YEAR
OF (YYYY)
Andrew Pecorini 91 Male EVENT 04 14 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens Ozanam Hall of Queens Nursing Home
CERTIFIER NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD 0 INTERMENT CREMATION CREMATION APPROVED BY:
OF ME/MLI Kara Storck
Ashwin Trivedi DISPOSAL ❑ OTHER M.E.CASE#Q20018330
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 1 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
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) I S� TU J J N.Y.STATE LIC.#
Thaddeus W. Baxter ' o i IlyAuthenticated 10227
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE _ UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department �•�� ��•ryi
of Health and Mental Hygiene;or if it has been corrected,
interlined or altered in an • • �—
y manner. Cly Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 15 /2020 .• •:fir* By-Service E_v_it_al
MM DD YYYY C�,OF •,NV�
Public Health Law Sec. 4145(2b) ' ~ 3'3 C
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#