Cruz, Adrian NEW YORK CITY THE CITY OF NEW YOR -DE
PARTMENT OF HEALTH AND MENTAL HYGIENE I{ �jj
DEPARTMENT OF HEALTH OFFIgE.QF VITAL RECORDS
AND MENTAL HYGIENE
April 24,2020 12:40 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-034746
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION - -c1=RrlFicnTe Nurasea
NAME First,Middle,Last AGE I SEX I DATE MONTH DAY YEAR
OF (YYYY)
Adrian Cruz 64 Male EVENT 04 14 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Bronx Lincoln Medical and Mental Health Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
OF ME/Mu Kristin Roman
Syeda Ali DISPOSAL ❑ OTHER M.E.CASE It B20022817
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DOTE MONTH DAY Y EAR
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.#
Michael Noll Si,n '.EkcvenialyAuftM-bd 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department
of Health and Mental Hygiene;or if it has been corrected, •?� Y
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 �N
New Leaf Cremation
Cruz, Adrian
TR042520 FH11/C05/033
Public Health Law Sec. 4145(2b) Q 13 6 3 6
Receipt
Human remains of delivered on , 20
' d
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#