Flores, Ubaldo Franco S` 5
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
May 05, 2020 05:11 PM 156-20-041134
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION 0 INDUCED TERMINATION -----------cEiiTiFicnre NuineeR
NAME First,Middle,Last AGE I SEX I DATE MONTH DAY YEAR
OF (YYYY)
Ubaldo Franco flores 67 Male EVENT 105 05 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Bronx 565 Prospect Ave,Apt 23, Bronx, NY 10455-4434
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT CREMATION OF ME/MLI Jeremy Stuelpnagel
Kristin Hord DISPOSAL ❑ OTHER M.E.CASE A B20041461
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF (YYYY)
DISPOSITION Pineview Crematory Queensbury, NY DISPOSITION 05 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) S TU J N.Y.STATE LIC.#
Thomas Roemmelt I E — — '"'"S�. .Im.fly Authenticated 13080
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE ti QUESTED ABOVE.
of ••�••
NOTICE: This permit is not valid without the seal of the Department �, �
of Health and Mental Hygiene;or if it has been corrected, • •?� '� �_
interlined or altered in any manner. Cfty RBgdC8f
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 05 / 08 /2020 % •� • " By_Service EvitaI
MIA Do YYYY �'•OF•tiE`�'y
Public Health Law Sec. 4145(2b) 013771
Receipt
1
t
1 Human remains of delivered on , 20 '
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#