Delma, Jean NEW YORK CITY //
THE CITY O TMENT OF HEALTH AND MENTAL HYGIENE L i 3
DEPARTMENT OF HEALTH VITAL RECORDS
AND MENTAL HYGIENE
April 19,2020 02:44 PM PERMIT TO DISPOSE R TRANSPORT HUMAN REMAINS
156-20-030849
EVENT:(CHECK ONLY ONE) 19 DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -------- cERTiFicaTe Niiaiseia -----
NAME First.Middle,Last AGESEX DATE MONTH DAY YEAR
OF (YYYY)
Jean Delma 681Male EVENT 104 18 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Brooklyn 1529 Brookl n Ave, Brooklyn, NY 11210-1930
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD U INTERMENT X CREMATION CREMATION APPROVED BY:
OF ME/MLI Sophia Rodriquez
Kristin Hord DISPOSAL ❑ OTHER M.E.CASE,K2002041 2
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
(YYYY)
DISPOSITION Pineview Crematory Queensbury, NY DISPOSITION 104 19 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 Beacl-fRd Island Park NY 02058
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Michael Noll cwka/ r Sig-WrerWw.ic y Auftnt.-q 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE r� UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ti°�•�� �-�.�a
of Health and Mental Hygiene;or if it has been corrected. •'
interlined or altered in any manner. Cry Registrar
VR 21(REV.7/09) FEE PAID s 40.00 DATE 04 21 (2020 ' •• . 0 By Service Evital
MM DID YYYY �yj1,OF 1 N
New Leaf Cremation
Delma, Jean
TR042520_FH11/CO5/027
Public Health Law Sec. 4145(2h - ^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#