Willis, Larry • _ -otl
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 11,2020 10:24 AM 156-20-023377
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION I-]INDUCEDTERMINATION ------------E anFionre riuMeeR.___-------
NAME First,Middle,Last AGE I SEX I DATE MONTH DAY EYY�R
LarryOF Willis 74 Male EVENT 04 06 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens Lonq Island Jewish Forest Hills
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD Zl INTERMENT 51 CREMATION CREMATION APPROVED BY:
OF ME/MLI Valerie Toodle
Bertrand Desir DISPOSAL ❑ OTHER M.E.CASE# Q20015842
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY OF lam)
DISPOSITION Pineview Crematory Queansbury, New York DISPOSITION 04 11 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 T8804
RESS CITY AND STATE N.Y.STATE REG.#
ESTABLISHMENT Gerard J. Neufeld, Inc. 43rd Ave Elmhurst NY 00661
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Omar J. Rodriguez mag nicallyAuthenticated 13073
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE _ UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department .�! � •' ?F Y Qy�
of Health and Mental Hygiene;or if it has been corrected,
interlined or altered in any manner. 's Cly Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 ( 11 )2020 •�. . By_Kathiravelu Kailayanathe
MM DD YYYY 41Y•w•!-
Of NEB
Public Health Law Sec. 4145(2b) 013
Receipt
Human remains of - delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#