Bonner, Delores NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE L)� o
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
April 24,2020 12:10 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
1_56-20-034702
_
EVENT:(CHECK ONLY ONE) DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -________
cERTiFicaTe NuiwseR�
NAME First.Middle,Last AGE SEX DATE MONTH DAY YEAR
OF
Delores Bonner 85 Female EVENT 04 20 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Brooklyn Crown Heights Center For Nursing and Rehabilitation
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD U INTERMENT CREMATION CREMATION APPROVED BY:
OF ME/MLI Carla Devito
Altaf Shaik DISPOSAL LJ OTHER M.E.CASE,K20022803
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 104 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.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Michael NQII I
cw%l�or signaNreEkctron aINAuM.06 1aE 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, �• `••s �Y � .l'�
interlined or altered in any manner. Cy Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 / 22 /2020 ' •� By Ser_v-ice Evital
MM DID YYYYOF Cyjyu '{
New Leaf Cremation
Bonner, Delores
TR042520_FH11/CO5/029
Public Health Law Sec. 4145(2b) � -3 5
Receipt
Human remains of delivered on , 20
,,1 P
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#