Mcdonald, Lucien NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
April 23, 2020 09:09 AM 156-20-033828
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Lucien Mcdonald 88 1 Male EVENT 04 17 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens Holliswood Care Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
CERTIFIER OF MEIMLI Adrienne Grande
Kamla Gurcharan DISPOSAL ❑ OTHER M.E.CASE#Q20022253
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY Y)
OF
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 104 24 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 Fox Funeral Home, Inc. 9807 Ascan Ave Forest Hills NY 00603
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) I S TU J J N.Y.STATE LIC.#
APPLICANT
Thaddeus W. Baxter 10227
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Departments
of Health and Mental Hygiene;or if it has been corrected,
interlined or altered in any manner. Cly Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 i 22 )2020 By
MM DD YYYY 4►).OF
I.
r. .
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on, , 20
Pine View Cemetery Representing the funeral home,named on burial permit
Official Funeral Directors Reg.or License#