Martinez, Eugenia 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 28,2020 09:10 PM 156-20-037522
EVENT:(CHECK ONLY ONE) ®DEATH ElSPONTANEOUS TERMINATION ElINDUCED TERMINATION -- --------cEariFicnre Nuniet=R
_
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Eugenia Martinez 93 1 Female EVENT 04 18 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens Long Island Jewish Forest Hills
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY'
CERTIFIER METHOD U INTERMENT CREMATION OF ME/MLI Kelly Mouer
Hyunyoung Park DISPOSAL ❑ OTHER M.E.CASE#Q20022965
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE I MONTH DAY YEAR
OF (YYYY)
DISPOSITION Pine View Crematorium Queensbury,New York DISPOSITION 04 29 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 rADCRESS CITY AND STATE N.V.STATE REG.#
ESTABLISHMENT House of Hills, Inc. 00 Saint Johns PI Brooklyn NY 00805
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) S ATU J N.Y.STATE LIC.#
Charise Hill-Wilkins SI re�AuthenBcated 11621
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE _ e� UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ���! �' � •� Q�/"
of Health and Mental Hygiene;or if it has been corrected, • • !Y
interlined or altered in an �• •�
y manner. City Registrar
VR21(REV.7/09) FEE PAID$40.00 DATE 04 / 23 /2020 By_Service Evital
MM DD YYYY Q/yti�y't
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#