Cabansag, Carmelita 4 . king
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 25, 2020 02:05 PM
- 156-20-035493
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION ------------cERriFicnre riuMeea
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Carmelita Cabansa 7$ Female EVENT 04 24 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens 6714 41 st Ave Apt 4F, Woodside, NY 11377-3707
CERTIFIER METHOD ❑ INTERMENT
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
� CREMATION
OF ME/MLI Lauren Mecca
Lauren Mecca DISPOSAL ❑ OTHER M.E.CASE# Q20022936
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION OF (YYYY)
Pine View Crematory Queensbury, NY DISPOSITION 05 01 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) SIGNATURE ��/�/y N.Y.STATE LIC.#
Steven Duca ai 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 a��•' ,;. r // ail
of Health and Mental Hygiene;or if it has been corrected, �• i Q/�
interlined or altered in any manner.: City Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 27 /2020 ij�•• . ••6 By
_Service_Ev_ital
MM DD YYYY 4lf,ofuVy
Public Health Law Sec. 4145(2b) 36 7'1.
i
Receipt
Human remains of: = delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#