Anolin, Myrna 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 28,2020 06:00 PM 156-20-037422
EVENT:(CHECK ONLY ONE) N DEATH El SPONTANEOUS TERMINATION El INDUCED TERMINATION -CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX I DATE I MONTH DAY (YEAR
YYYY)
OF
Myrna Anolin 75 1 Female EVENT 04 27 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens Long Island Jewish Forest Hills
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION
CREMATION APPROVED BY:
�
OF MFJMLI Joseph Pestaner
Yolanda Beck DISPOSAL ❑ OTHER M.E.CASE#Q20024268
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF (YYYY)
DISPOSITION Pine View Crematory Queensbury, NY 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.
FUNERAL
NAME OF ESTABLISHMENT [ADDIRESq CITY AND STATE N.Y.STATE REG.#
ESTABLISHMENT FOX Funeral Home, Inc. 7 Ascan Ave Forest Hills NY 00603
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGN}j�� N.Y.STATE LIC.#
Steven Duca �l�^lJ1►(( '' � Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE 1� UESTED ABOVE. l
NOTICE: This permit is not valid without the seal of the Department ���•'� ��•'�
of Health and Mental Hygiene;or if it has been corrected, 3100'. i
interlined or altered in an �0 •
y manner. City Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 27 /2020 ' •• •• * By Service Evital
MM DD YYYY
Public Health Law Sec. 4145(2b) 01 13 6 d _
Receipt
Human remains of r' ' ` ' delivered on ! ' , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#i