Capellan, Katia NEW YORK CITY THE CITY OF NEW YORK—DEPAFi—_.., OF HEALTH AND MENTAL HYGIENE '
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
April 17,2020 06:34 PM 156-20-029675
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EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE
MONTH DAY (YYYV)
Katia Capellan OF
80 Female EVENT 04 16 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens Long Island Jewish Forest Hills
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD D ❑ INTERMENT CREMATION ME/MLI Anne Laib
Mark Richman
DISPOSAL ❑ OTHER M.E.CASE.1 Q20019711
NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY (YYYY)
PLACE OF OF
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 04 18 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) SIGN�� N.Y.STATE LIC.#
APPLICANT
Steven Duca i Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE REy UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department • • q•Z Kj a�r
of Health and Mental Hygiene;or if it has been corrected, •. y
interlined or altered in any manner. • City Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 16 /2020 • 00 By-Service Evital
MM DD YYYYOfNy
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#