Moran, Bertha -�3S-1
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
May 08,2020 10:51 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-042711
EVENT:(CHECK ONLY ONE) X DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION - CERTIFICATE NUMBER_._.
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF
Bertha Moran 56 Female EVENT 05 04 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW PORK CITY
EVENT Bronx Jacobi Medical Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD U INTERMENT X CREMATION OF ME/MLI Adrienne Licking
Levi White DISPOSAL :1 OTHER M.E.CASE#B20043086
NAME OF CEMETERY OR CREMXPORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
PLACE OF OF (YYYY)
DISPOSITION Pineview Crematory Queensbury, NY DISPOSITION 105 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 ADDRESS CITY AND STATE N.Y.STATE REG.#
ESTABLISHMENT John J.Fox Funeral Home, Inc.(Bronx) 203 E 201st St Bronx NY 00897
APPLICANT
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
C14 �nnie/�
Thomas Roemmelt SgreNreElactronifalFyAu�n4cabE 13080
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
of •!�`�''�ey
NOTICE: This permit is not valid without the seal of the Department
of Health and Mental Hygiene;or if it has been corrected, •s
interlined or altered in any manner. �i: �� City Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 05 / 05 /20�0 '�•� �:' By Service_Ev_ital
MM DD YYYY 4Tr� � �
Of NEY'
Public Health Law Sec. 4145(2b) j
Receipt
Human remains of delivered on , 20
Pine`View Cemetery Representing the funeral home named on burial permit
Official Funeral Direciors Reg.or License#