Avellaneda, Mercedes Y k3'
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
April 16,2020 11:44 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-028153
EVENT:(CHECK ONLY ONE) X DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE I SEX I DATE I MONTH DAY �
Mercedes Avellaneda 95 Female EVE rr 04 12 202(
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW PORK CITY
EVENT Queens Ozanam Hall of Queens Nursing Home
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ] INTERMENT X CREMATION CREMATION APPROVED BY:
OF ME/MLI Michael Vaivao
Vincent A Puccia DISPOSAL :1 OTHER M.E.CASE I Q20018899
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR OF (YYYY)
DISPOSITION Pineview Crematory i Queensbury, New York DISPOSITION 04 1$ 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 IA66RESS CITY AND STATE N.Y.STATE REG.#
ESTABLISHMENT Gerard J. Neufeld, Inc. 804 43rd Ave Elmhurst NY 00661
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) I SIGNATURE N.Y.STATE LIC.#
Omar J. Rodriguez I cmazcy- C- SIF.—EW.—WAM..Wd 13073
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
•�•
NOTICE: This permit is not valid without the seal of the Department �,�l��" "��•�
of Health and Mental Hygiene;or if it has been corrected, •' `#-{''••ice Q� ./�
interlined or altered in any manner. ;'
2 City Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 / 16 /2020 ' •� �• • By Service Evital
MM DD YYYY 431.••� ,Y
OF NEV"
�,.
Public Health Law Sec. 4145(2b) - - 013580
Receipt
Human remains of delivered on , 20—
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#