Del Rosario, Kevin Bernabe t 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 27, 202011:20 AM 156-20-036397
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX I DATE MONTH DAY YEAR
OF (YYYY)
Kevin Bernabe Del rosario 30 Male EVENT 04 23 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Manhattan Bellevue Hospital Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
I$
OF ME/MLI Jelena Krcedinac
Jelena Krcedinac DISPOSAL ❑ OTHER �M.E.CASEO M20022385
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION OF (AY)
Pine View Crematory Queensbury, NY 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 rAD8DRESS CITY AND STATE N.Y.STATE REG.#
ESTABLISHMENT Fox Funeral Home, Inc. 7 Ascan Ave Forest Hills NY 00603
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE - N.Y.STATE LIC.#
Steven Duca C�J (.Gi.l.1/ Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department =~�•'
of Health and Mental Hygiene;or if it has been corrected, •
interlined or altered in any manner.: City Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 25 /2020 •• . By agrvice_Evital
MM DD YYYY OF NO
Public Health Law Sec. 4.145(2b) 113 6 � f
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeial home named on burial permit
Official Funeral Directors Reg.or License#