Sutanto, Herry 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 10,2020 07:59 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-023124
EVENT:(CHECK ONLY ONE) X DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION """""""""CERTIFICATE-TE NUMBER -'
CERTIFlCATE NUMBER
NAME First,Middle,Last AGE I SEX DATE MONTH DAY YEAR
-
OF
Her Sutanto 59 Male EVENT 04 04 2021
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens Elmhurst Hospital Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION
CREMATION APPROVED BY:
OF ❑
Liliana Cruz DIS OLI{M.E.SAL OTHER Interim ME.CASE S
NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE ONT PLACE OF DATE M H DAY YEAR
DISPOSITION Pineview Crematory Queensbury, New York OF (YYYY)DISPOSITION 04 18 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. (I
ESTABLISHMENT I Gerard J. Neufeld Inc. 88-04 43 Ave Elmhurst, NY 00661
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Joseph Neufeld f' e*Tmddd 12624
SggM EleevonoN MIrWeMtl
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
P a •���• .
NOTICE: This permit is not valid without the seal of the Department ���` .�•�
of Health and Mental Hygiene;or if it has been corrected, • •sue L���a���If� �y /
interlined or altered in any manner. : . y RegWrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 / 16 /2020 •• •0 By Service_E_vital
MM DD YYYY •••
OF"
Hof/cod m
Public Health Law Sec. 4145(2b) 3 6 2 3
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#