Lopez, Jose NEW YORK CITY `"``
THE CITY OF NEW YORK—DEPA�t'FIWENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
April 29,2020 09:15 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-038115
EVENT:(CHECK ONLY ONE) X DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION cEirriFlcare NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF
Jose Lopez 71 Male EVENT 104 25 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Staten Island Golden Gate Rehab& Healthcare Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
METHOD ❑ INTERMENT CREMATION
CERTIFIER OF ME/MU Kristin Roman
Noreen Tan-Chu DISPOSAL ❑ OTHER M.E.CASE#R20035408
NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
PLACE OF
OF YYYY)
DISPOSITION Pineview Crematory Queensbury, New York DISPOSITION 05 01 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 D'Arienzo Funeral Home, Inc. 104 Skillman Ave Brooklyn NY 00407
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) I SIGNATURE N.Y.STATE LIC.#
APPLICANT �' 10843
John O D Arienzo SEY
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ���" "�••� i� f!of Health and Mental Hygiene;or if it has been corrected, • •?� /46pl
interlined or altered in any manner. 0_ City Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 / 26 DD j202Y0 l?_.•: •��t BY Service_Eyital
�i'�'OF 14E`� --
Public Health Law Sec. 4145(2b) �' ..J z
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#