Dore, Robert #Y2Z
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 21, 2020 01:39 PM 156-20-032396
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION ------------cEariFicnre NUMeea
NAME First,Middle,Last AGE SEX DATE MONTH DAY ( )
-T
OF
Robert Dore 91 Male EVENT 04 20 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW PORK CITY
EVENT Queens Long Island Care Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
OF MElMLI Michael Vaivao
Reena J Patel DISPOSAL ❑ OTHER M.E.CASE# Q20021472
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DAATE MONTH DAY Y YEAR
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION
04 22 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
APPLICANT
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Steven Duca CJ WlM/ Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department �� ''+,!•!F �/Q/'
of Health and Mental Hygiene;or if it has been corrected, �• •s '/����6 ,/Y QII� ,1'�
interlined or altered in any manner. City Registrar
VR21(REV.7/09) FEE PAID$40.00 DATE 04 / 21 /2020 •• . •� By Service Evital
MM DD YYYY ••• 4
�'OF NfN
Public Health Law Sec. 4145(2b) 01, 3616
Receipt
Human remains of ' delivered on ' , 20—
Pine View Cemetery Representing the fuiieraf home named on burial permit
Official Funeral Directors Reg.or License#