Floyd, John Vincent NEW YORK CITY THE CITY OF NEW YORK-Uk ARTAENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
April 19,2020 08:14 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-031118
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ElINDUCED TERMINATION -----------cEarlFicaTe i iwsea
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF
John Vincent Floyd 66 Male EVENT 104 19 202E
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens FlushingHos ital Medical Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT j�CREMATION ME/MLI Kimberly Winston
Marcelle Pignanelli DISPOSAL ❑ OTHER M.E.CASE H Q20022351
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY 1 WY)
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.
NAME OF ESTABLISHMENT ADDRESS CITY AND STATE N.Y.STATE REG.#
FUNERAL
ESTABLISHMENT New Leaf Cremation 3930 Long Beach Rd Island Park NY 02058
APPLICANT NAME OF N.V.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Michael Noll I cwuA�dl�oi S,g-Wr.rkI.N.IyAutheM.Wd 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, • '����G�y�� �� Q/J�/ :1'�'
interlined or altered in any manner. ' Cry Registrar
• •�,
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 24 /2020 0 By Service_Evital
MM DD YYYY CyA, 0
OF N
New Leaf Cremation
Floyd, John C051041
TR042520_FH11/
Public Health Law Sec. 4145(2b) 'J 13 6 3 q
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#