O'Brien, Mary j . Anj
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 18,2020 07:19 PM 156-20-030446
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX I DATE MONTH DAY YEAR
OF
Ma O`brien 94 1 Female I EVENT 04 17 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW PORK CITY
Queens New York-Presbyterian Queens
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD 0 INTERMENT CREMATION CREMATION APPROVED BY:
CERTIFIER O� ME/MLI Zhanna Georgievskaya
Temitope Adedimeji DISPOSAL O OTHER M.E.CASE* Q20020320
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION OF (YYYY)
Pine View Crematory Queensbury, NY DISPOSITION 04 20 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 ADDRESS CITY AND STATE N.V.STATE REG.#
ESTABLISHMENT Fox Funeral Home, Inc. 1 9807 Ascan Ave Forest Hills NY 00603
APPLICANT
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
�,�'/n�/ryyi.1.1/
Steven Ducal (� (.(� Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
6 ••`'S'•,+
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NOTICE: This permit is not valid without the seal of the Department •
of Health and Mental Hygiene;or if it has been corrected, : • �� ��f� r`j � Q'Il��
interlined or altered in any manner. City Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 18 /2020 ",•• . •.•' By_Service_EvitaI
MM Do
YVYY Of MEryy
Public Health Law Sec. 4145(2b) J 1,3 5 7 5
Receipt
f
Human remains of delivered on; `;�'. 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# µ'"
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