Bowen,Vernon NEW YORK CITY `173
THE CITY OF NEW`IbRK'•-[;iEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
April 24,2020 12:35 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-034741
EVENT:(CHECK ONLY ONE) X DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -- - ci=RTlficnTe niiiansER_
NAME First,Middle,Last AGE SEX DATE MONTH DAY YYYY
OF ( )
Vernon Bowen 77 Male EVENT 104 21 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens St. John's Episcopal Hospital
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD U INTERMENT X CREMATION CREMATION APPROVED BY:
OF ME/MLI Kristin Roman
Raphael Sayoc DISPOSAL LJ OTHER M.E.CASE#Q20022823
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF ( )
DISPOSITION Pineview Crematory Queensbury, NY DISPOSITION 04 25 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 New Leaf Cremation 3930 Long Beach Rd Island Park NY 02058
APPLICANT
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
c�,�
Michael Noll �� Y6u Oer Si9naWmEk —ic l�,AulhenOwetl 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
of •!*�•�
NOTICE: This permit is not valid without the seal of the Department 3�� 4•:�
of Health and Mental Hygiene;or if it has been corrected, i
interlined or altered in any manner. Cry Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 ) 22 )2020 %.� By Service Evital
MM DD YYYY C)jl OF N 1
New Leaf Cremation
Bowen,Vernon
TR042520 FH11/CO5/035
Public Health Law Sec. 4145(2b) y 0 i 3 6 6
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#