Deb, Shamir NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OF "OF'VITAL RECORDS
AND MENTAL HYGIENE
May 09, 202011:21 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-042787
EVENT:(CHECK ONLY ONE) X DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION - "---- - ` T-F-ICATE-""'---BER------------
CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX I DATE [MONTH DAY YEAR
OF (YYYY)
Shamir Deb 58 Male EVENT 05 03 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Manhattan New York Weill Cornell Medical Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER MEO�OD U INTERMENT CREMATION I ME/MLI Madeline Ahmad
Diana Berman DISPOSAL U OTHER M.E.CASE a M20042838
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
(YYYY)
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 05 12 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 New Leaf Cremation 3930 Long Beach Rd Island Park NY 02058
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) ISIGNATURE N.Y.STATE LIC.#
Michael Noll rcWK:i�cAOeD
Signal—El—omk llyAWhenfi—d 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department
of Health and Mental Hygiene;or if it has been corrected, :' r
interlined or altered in any manner.
.9 Cly RegWror
VR 21(REV.7/09) FEE PAID$40.00 DATE 05 ( 04 /2020 i000. 0. By Service Evital
MM DD YYYY G}n OF N
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- s
Public Health Law Sec. 4145(2b) 01. 37Q6
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#